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 D
Explanation
Informed consent is a critical step before any invasive procedure, including an EGD. The nurse should confirm that the client has received the necessary information about the procedure, its risks and benefits, and has given their consent voluntarily. This ensures that the client understands the procedure and its implications, making it an essential part of their rights and safety.
Correct Answer is C
Explanation
Choice A Reason:
Hypoglycemia (low blood sugar) is not a common adverse effect of atorvastatin.
Choice B Reason:
Daytime drowsiness is not a typical side effect of statin medications and is more commonly associated with other types of medications, such as sedatives or sleep aids.
Choice C Reason:
Muscle pain is correct. The nurse should instruct the client to monitor and report muscle pain (myalgia) to the healthcare provider when taking atorvastatin. Myalgia is a potential adverse effect of statin medications, and in rare cases, it can progress to a more serious condition called rhabdomyolysis, which involves muscle breakdown and can lead to kidney damage. Therefore, any new or unexplained muscle pain, tenderness, or weakness should be reported promptly to the healthcare provider for evaluation.
Choice D Reason:
Palpitations (rapid or irregular heartbeats) are not commonly associated with atorvastatin use. If a client experiences palpitations, it may be related to other factors or conditions and should be evaluated separately.
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