A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?
Determine the client's level of consciousness
Administer an anxiolytic medication.
Keep lights on in the client's room.
Encourage visits from family members.
The Correct Answer is A
Choice A Reason:
Determining the client's level of consciousness is correct. Delirium is characterized by a sudden change in mental status, including altered consciousness, confusion, and impaired attention. Assessing the client's level of consciousness helps the nurse understand the severity of the condition and whether the client is experiencing any immediate risks.
Choice B Reason:
Administer an anxiolytic medication is incorrect. Medication administration should not be the first action because the nurse needs to assess the client's condition first to determine if medication is appropriate. Additionally, the underlying cause of the delirium should be identified and treated if possible.
Choice C Reason:
Keep lights on in the client's room is incorrect. While maintaining proper lighting can be important for safety, it is not the first action because it doesn't address the underlying cause or assess the client's level of consciousness.
Choice D Reason:
Encouraging visits from family members is incorrect. Involving family members can provide emotional support, but it's not the first action because the client's condition should be assessed and stabilized before involving others in care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Uses a firm-bristled toothbrush is correct. Clients with pernicious anemia often have neurological symptoms due to vitamin B12 deficiency. One of these neurological symptoms can be impaired proprioception, which is the body's ability to sense its position and movement in space. Using a firm-bristled toothbrush can increase the risk of injury because the client may have difficulty with fine motor skills and controlling the pressure applied to their teeth and gums, leading to potential gum injury or bleeding.
Choice B Reason:
Increased intake of green, leafy vegetables is incorrect. Increasing the intake of foods rich in vitamin B12, such as green, leafy vegetables, can be beneficial for clients with pernicious anemia, as it can help with vitamin B12 absorption and overall health.
Choice C Reason:
Drinks 2,500 mL of fluid per day is incorrect. Maintaining adequate hydration is essential for overall health and does not increase the risk of injury.
Choice D Reason:
Wears a face mask around others is incorrect. Wearing a face mask around others, especially in situations where respiratory precautions are necessary, is a preventive measure to reduce the risk of infection and does not inherently increase the risk of injury.
Correct Answer is C
Explanation
Choice A Reason:
Flossing between a 12-month-old's teeth is not typically necessary, as most children do not have enough teeth for flossing at this age. Flossing becomes more important as a child's dentition develops.
Choice B Reason:
Positioning the toothbrush bristles at a 90-degree angle is not appropriate for a 12-month-old child. Parents should use a gentle, circular brushing motion, as this is more effective and less likely to cause discomfort or injury to the child's gums and teeth.
Choice C Reason:
Cleaning the teeth with a small, soft-bristled toothbrush is correct. When teaching a parent about preventing dental caries in a 12-month-old toddler, it's important to provide appropriate guidance for oral care. Using a small, soft-bristled toothbrush is recommended for young children because it is gentle on their gums and teeth. Here's why the other options are not suitable:
Choice D Reason:
Using a 5-inch strip of toothpaste on the toothbrush is excessive for a 12-month-old. The American Academy of Pediatrics recommends using only a small smear or grain-sized amount of fluoride toothpaste for children under 3 years old to minimize the risk of swallowing too much fluoride.
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