A nurse is caring for an older adult client.

Exhibits

Complete the following sentence by using the list of options.

Upon assessment, the nurse should recognize that the client is at risk for developing
dropdown
as evidenced

by the client's
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Upon assessment, the nurse should recognize that the client is at risk for developing delirium as evidenced by the client's orientation.

Rationale:

Delirium is an acute confusional state characterized by disturbances in attention, awareness, and cognition. It can be triggered by infections, medications, or other acute medical conditions, such as the urinary tract infection (UTI) in this client. The client is displaying confusion about time and place, agitation, and an inability to focus, all of which are key signs of delirium. Additionally, reorientation worsens the agitation, which is typical in delirium, as patients often cannot tolerate attempts to correct their disorientation.

In contrast, dementia is a chronic condition with a gradual onset of memory loss and cognitive decline, and stroke typically presents with sudden neurological deficits, which are not observed in this case.

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Correct Answer is A

Explanation

A. Electroconvulsive therapy (ECT) is primarily used to treat severe depression, and its effectiveness is demonstrated through an improvement in depressive symptoms such as mood, energy levels, and interest in daily activities.
B. While ECT may have some effect on panic attacks, its primary indication is for severe depression. Therefore, a reduction in panic attacks is not the best indicator of the treatment's effectiveness.
C. Seizures are part of the therapeutic process in ECT, and the goal is not to reduce their frequency but to alleviate psychiatric symptoms.
D. Decreased fear of heights may be beneficial for some clients, but it is not a direct indicator of the effectiveness of ECT, which targets depression rather than specific phobias.

A. Smoking history B. Client's recent consumption of alcohol C. Blood alcohol level D. Client's recent loss E. Respiratory assessment F. Neurological assessment G. Cardiac assessment H. Gastrointestinal assessment I. Genitourinary assessment

Correct Answer is ["B","C","D","E","F"]

Explanation

A. Smoking history: Although the client quit smoking over 20 years ago, there is no immediate concern with their smoking history in this admission. The focus is on the current alcohol-related issues, as smoking history does not have a direct, immediate impact on the client's current condition.
B. Client's recent consumption of alcohol: The client has a history of alcohol use disorder and has been drinking continuously since the death of their parents. Monitoring alcohol consumption and its effects is crucial for evaluating withdrawal symptoms and preventing complications like delirium tremens, which can occur in severe alcohol withdrawal.
C. Blood alcohol level: Since the client has consumed alcohol recently (within the past 2 hours), it is important to assess their blood alcohol level to determine the extent of intoxication and potential risks associated with alcohol withdrawal. This helps guide immediate management and interventions.
D. Client's recent loss: The death of the client's parents is a significant stressor that likely contributed to the relapse in alcohol use. This emotional distress should be addressed as part of the care plan, as it may be influencing the client's mental and emotional state, which can impact their recovery process.

E. Respiratory assessment: The client has a respiratory rate of 10/min, which is low and could be indicative of respiratory depression, especially if the client is intoxicated or if withdrawal symptoms are imminent. Monitoring respiratory status is important to ensure adequate oxygenation and detect early signs of respiratory distress.
F. Neurological assessment: The client is intoxicated and exhibiting slurred speech, which suggests neurological impairment. It is important to monitor the client's neurological status for any signs of complications such as confusion, altered consciousness, or the onset of alcohol withdrawal seizures or delirium.
G. Cardiac assessment: The client has a normal heart rate and rhythm upon initial assessment, and there is no indication of cardiovascular distress. While cardiovascular monitoring is important, the client's current condition does not show any immediate signs that require further follow-up.
H. Gastrointestinal assessment: Although the client reports weight loss and a minimal appetite, these findings are likely related to their alcohol use disorder and could be addressed as part of the ongoing management of the condition. However, this does not require immediate follow-up compared to the more urgent issues related to intoxication and withdrawal.
I. Genitourinary assessment: The client reports no known problems, and there are no immediate concerns about their genitourinary system. This assessment is less of a priority at this time compared to monitoring for alcohol-related issues.

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A nurse is caring for an older adult client. Exhibits Complete the following sentence by using the list of options. Upon assessment, the nurse should recognize that the client is at risk for developing dropdown as evidenced by the client's dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?

Correct Answer is A

Explanation

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse in a mental health facility is making plans for a client's discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement?

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A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?

A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?

A nurse is caring for a client who is experiencing alcohol withdrawal. Exhibits A nurse is planning care for a client who has alcohol use disorder. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

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A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?

A nurse is caring for an older adult client.

Exhibits

Complete the following sentence by using the list of options.

Upon assessment, the nurse should recognize that the client is at risk for developing
dropdown
as evidenced

by the client's
dropdown