A nurse is caring for an older adult client.
Complete the following sentence by using the list of options.
Upon assessment, the nurse should recognize that the client is at risk for developing
by the client's
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement is an example of generalizing, where the client makes a broad statement without recognizing specific instances or nuances. "Always criticizing" is an overgeneralization and may not accurately reflect the situation.
B. Manipulating involves influencing or controlling others in an indirect or deceptive way. The statement does not suggest manipulation but rather a complaint about perceived behavior.
C. Distracting communication occurs when someone diverts attention away from the topic. The statement does not exhibit this behavior; it is a direct expression of concern.
D. Placating involves trying to calm someone down or please them to avoid conflict. The client's statement is more accusatory than an attempt to placate.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The client is at risk for developing Dysphoria as evidenced by the client's history of alcohol consumption.
Rationale:
Dysphoria is a state of unease or dissatisfaction, which is common among individuals experiencing alcohol use disorder, particularly those with a history of alcohol consumption. The client’s history of excessive alcohol intake, compounded by the stress of their parents' deaths and current life circumstances, places them at significant risk for dysphoria, especially during the withdrawal process or when coping with emotional distress.
History of alcohol consumption: The client’s longstanding alcohol use disorder, spanning over 20 years, directly contributes to the increased risk of developing dysphoria. Alcohol misuse can impact mood regulation and may exacerbate symptoms of depression, anxiety, or irritability, especially in the context of a recent relapse.
Incorrect choices:
Stroke: While alcohol use disorder is a risk factor for stroke, particularly due to its effects on blood pressure and clotting, the current focus on the client’s immediate symptoms (intoxication and withdrawal risk) makes stroke a less immediate concern in this context.
Dementia: While chronic alcohol use can increase the risk of developing alcohol-related dementia over time, it is not directly related to the current presentation, which centers more on acute alcohol use disorder and withdrawal symptoms rather than long-term cognitive decline.
Age: Age alone is not sufficient to explain the client's risk for developing dysphoria or alcohol-related complications. The client's history of alcohol use disorder and the recent emotional stress are more relevant to the current risk assessment.
History of rehabilitation: The client’s past experience with rehabilitation does not necessarily increase the risk for developing dysphoria but indicates that the client has sought treatment before. While a history of rehabilitation might inform their treatment plan, it is not a direct risk factor for dysphoria in this case.
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