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 B
Explanation
Choice A Reason:
Removing personal protective equipment (PPE) after leaving the client's room is correct, but it should be done in a way that minimizes the risk of contamination. Proper doffing of PPE is essential to prevent self-contamination.
Choice B Reason:
Wear a gown when assisting the client with personal hygiene. When caring for a client with methicillin-resistant Staphylococcus aureus (MRSA) in a long-term care facility, wearing a gown when assisting the client with personal hygiene is an important infection control measure. MRSA can be transmitted through direct contact with contaminated surfaces or skin, so wearing a gown can help prevent the spread of the bacteria from the client to the healthcare provider's clothing.
Choice C Reason:
Ensuring that negative air pressure is active for the client's room is not typically necessary for MRSA precautions. Negative air pressure rooms are often used for clients with airborne infectious diseases, such as tuberculosis.
Choice D Reason:
Restricting the client's visitors may be necessary in some cases, especially if there is a concern about the potential spread of MRSA to vulnerable individuals. However, visitor restrictions should be implemented based on the facility's policies and guidelines, and they should be communicated clearly to visitors and family members.
Correct Answer is A
Explanation
Choice A Reason:
Yellow patches in the mouth. Yellow patches in the mouth are indicative of a candida infection, specifically oral candidiasis, which is commonly known as thrush. Candida is a type of yeast that can overgrow in the mouth, leading to the development of creamy or yellowish-white patches on the tongue, inner cheeks, and other oral mucosal surfaces. These patches are often described as "cottage cheese-like" in appearance.
Choice B Reason:
Brittle nails are more commonly associated with conditions like fungal nail infections or nail trauma.
Choice C Reason:
Night sweats can occur for various reasons, including hormonal changes, infections, or underlying medical conditions, but they are not specific to candida infections.
Choice D Reason:
Hearing loss is not a typical symptom of candida infections but may be associated with ear infections or other ear-related conditions.
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