Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for an older adult client who is postoperative.

Exhibits

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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Arranging a visit without the client’s consent disregards their right to refuse visitors, which is important to respect their autonomy.

Choice B rationale

Referring the sibling to the provider does not address the client’s current refusal and bypasses the nurse’s role in facilitating communication.

Choice C rationale

Informing the sibling that the client does not want visitors respects the client’s wishes and maintains their confidentiality.

Choice D rationale

Encouraging the client to visit with the sibling may pressure the client and does not respect their current refusal of visitors. .

A. Cold extremities. B. Diarrhea. C. Tooth erosion. D. Lanugo.

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Cold extremities are a common finding in individuals with anorexia nervosa due to poor circulation and reduced body fat, which impairs the body's ability to maintain normal temperature.

Choice B rationale

Diarrhea is not typically associated with anorexia nervosa. Instead, individuals with this disorder often experience constipation due to restrictive eating and decreased bowel movements.

Choice C rationale

Tooth erosion is a common finding in individuals with anorexia nervosa, particularly those who engage in self-induced vomiting, as stomach acid erodes the enamel on teeth.

Choice D rationale

Lanugo, or fine, soft body hair, is a common finding in individuals with anorexia nervosa as the body attempts to conserve heat due to loss of insulating body fat.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is speaking with the sibling of a client who refuses to see visitors.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has anorexia nervosa.Which of the following findings should the nurse expect?

Correct Answer is ["A","C","D"]

Explanation

A nurse is participating in a community program about eating disorders.Which of the following information about bulimia nervosa should the nurse include in the presentation?

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSD

A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy.The nurse should notify the provider for which of the following findings?

A nurse is collecting data from an adult client in an outpatient mental health clinic.The nurse should identify which of the following events as a potential cause of a maturational crisis?

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium.To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?

A nurse is caring for a client who has depression and reports only sleeping a few hours each night.Which of the following instructions should the nurse give the client to promote sleep?

A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder.Which of the following statements by the parent indicates an understanding of the redirection technique?

A nurse is collecting data from a client who has antisocial personality disorder.Which of the following findings should the nurse expect?