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 D
Explanation
Choice A rationale
Relaxation exercises can help manage anxiety but are not the immediate first action required for a newly admitted client.
Choice B rationale
Explaining response prevention is useful for OCD treatment but isn't the first priority upon admission.
Choice C rationale
Administering medication can alleviate anxiety symptoms but isn't the first action that establishes a comprehensive assessment.
Choice D rationale
Calculating the Hamilton Rating Scale for Anxiety provides an initial assessment of the client's anxiety severity, guiding further interventions.
Correct Answer is A
Explanation
Choice A rationale
Demonstrating a neutral demeanor helps build trust with a client who has a paranoid personality disorder. This approach is non-threatening and avoids triggering the client's suspicious tendencies.
Choice B rationale
Using an overly friendly approach can increase the client's suspicion and anxiety, making them feel manipulated or deceived.
Choice C rationale
Asking the client why they are suspicious can be perceived as confrontational and may cause the client to become defensive and less cooperative.
Choice D rationale
Being vague when answering the client's questions can increase their paranoia and mistrust, as it may seem like the nurse is hiding something.
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