A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications?
Postoperative cognitive dysfunction
Dementia
Alzheimer's disease
Postoperative delirium
The Correct Answer is D
A. Postoperative cognitive dysfunction refers to a long-term decline in cognitive function after surgery, often seen in older adults, but it is not characterized by temporary disorientation. Delirium, on the other hand, is temporary and can present as disorientation shortly after surgery.
B. Dementia is a chronic condition marked by long-term cognitive decline, not a temporary state. Dementia typically develops over time, unlike the acute onset of disorientation seen in postoperative delirium.
C. Alzheimer’s disease is a progressive neurodegenerative disease leading to cognitive decline, which occurs gradually over time. Temporary disorientation immediately after surgery is not a symptom of Alzheimer's.
D. Postoperative delirium is an acute, often reversible, confusion or disorientation that typically occurs after surgery, particularly in older adults. It can be triggered by anesthesia, medications, or other factors and is characterized by temporary cognitive disturbances such as disorientation.
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Related Questions
Correct Answer is C
Explanation
A. Providing more stimulation might not address the root cause of the behavior and could escalate the situation if the client becomes more agitated or confused.
B. Waiting to see if the behavior continues is not the most appropriate action, as it may delay necessary interventions. Additionally, it could increase the risk of harm to the client.
C. Calling the doctor to obtain a prescription for a restraint, if necessary, is the correct procedure. Restraints should only be used as a last resort, following proper protocols, and should always be ordered by a physician.
D. Covering the catheter so the client cannot see it might not address the underlying issue and is not an appropriate solution to managing behavior. It may also be a safety concern if it interferes with monitoring or use of the tube.
Correct Answer is B
Explanation
A. Assisting the client to a low Fowler's position (15 to 30 degrees) is not appropriate for enteral feedings. The client should be positioned at a higher angle (30 to 45 degrees) to reduce the risk of aspiration and improve digestion during feeding.
B. Testing the pH of gastric aspirate is essential to confirm that the NG tube is in the correct position (i.e., the stomach). A pH of 1 to 4 indicates gastric placement, while higher pH values suggest the tube may be in the lungs or intestines. This is a crucial step to ensure safety before administering the feeding.
C. Discarding residual gastric contents is not the correct action. Residual gastric contents should be measured to assess gastric motility and tolerance to the feeding. The feeding should only be withheld if the residual volume is excessive, based on institutional guidelines.
D. Warming the feeding solution to body temperature is not always necessary, although it is often recommended to improve comfort and prevent cramping. The most important step is confirming tube placement and ensuring the feeding is safe.
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