A nurse is caring for an older adult client who is postoperative.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
The Correct Answer is []
Condition: Delirium.
2 actions:
Encourage family members to stay with the client,
Monitor the client's fluid intake and output.
2 parameters:
Fall risk,
Sleep-wake cycle.
Rationale for correct condition: Delirium is indicated by the sudden onset of disorientation, confusion, and changes in mental status. Postoperative status, dehydration, and infection contribute to delirium. The client's symptoms began recently and are acute. Delirium often presents with restlessness and disturbed sleep. Immediate intervention is crucial to prevent further deterioration.
Rationale for actions: Family presence provides reassurance and helps reorient the client. Familiar faces can reduce anxiety and confusion. Monitoring fluid intake and output addresses dehydration, a common delirium trigger. Ensuring proper hydration can improve mental status. Identifying coping skills is less urgent in acute delirium. Encouraging exercise is inappropriate until the client stabilizes.
Rationale for parameters: Monitoring fall risk is crucial due to the client's confusion and agitation. Preventing falls ensures safety. Tracking the sleep-wake cycle helps assess delirium severity and improvement. Delirium often disrupts sleep patterns. Suicidal ideation is less likely related to delirium. Weight loss is not an immediate concern. Oxygen saturation is stable, irrelevant for delirium.
Rationale for incorrect conditions: Depression presents with prolonged low mood, not sudden confusion. Alzheimer's disease involves gradual cognitive decline, unlike acute delirium. Generalized anxiety disorder does not explain acute disorientation and restlessness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Scheduling long teaching sessions is not effective for older adults, as it can lead to fatigue and decreased attention. Short, focused sessions are more beneficial to promote participation and information retention among older adults, who may have limitations in concentration and stamina.
Choice B rationale
Using "I" statements rather than "you" statements helps build rapport and reduces defensiveness. It fosters a supportive learning environment by focusing on the instructor's perspective and experiences, making the communication more personal and less confrontational.
Choice C rationale
Assisting clients in establishing long-term goals is important but not the primary method to eliminate learning barriers. Effective teaching strategies for older adults should prioritize immediate and relevant information that can be easily understood and applied, rather than focusing solely on long-term planning.
Choice D rationale
Ensuring teaching sessions occur right before bedtime is not advisable for older adults, as they may be tired and less receptive to new information. Optimal learning times should be chosen based on the clients' energy levels and alertness, typically earlier in the day.
Correct Answer is D
Explanation
Choice A rationale
Drinking alcohol before bed can disrupt sleep patterns and reduce overall sleep quality. While alcohol may initially induce drowsiness, it can lead to fragmented sleep, causing more awakenings during the night.
Choice B rationale
Eating a meal just before bedtime can cause discomfort and interfere with the ability to fall asleep. The body's digestion process can disrupt the onset of sleep and reduce sleep quality.
Choice C rationale
Taking a nap after lunch can interfere with the body's natural sleep-wake cycle, making it more difficult to fall asleep at night. Napping late in the day can reduce the need for sleep at bedtime.
Choice D rationale
Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep. Reducing caffeine consumption, especially in the afternoon and evening, can improve sleep quality.
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