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 []

Potential Condition: Delirium The client’s symptoms such as disorientation to time and place, disorganized thinking, lack of attention, rambling speech, and changes in behavior that began the prior evening suggest the client is most likely experiencing delirium12. Delirium is common in older adults who are postoperative and can be triggered by factors such as dehydration, infection, and certain medications.

Actions to Take:

Choice A: Monitor client’s fluid intake and output The client has refused to eat or drink since the previous day and has a significant difference between intake (250 mL) and output (2,500 mL), suggesting possible dehydration3. Monitoring the client’s fluid intake and output can help assess the client’s hydration status and the effectiveness of interventions such as IV fluid administration.

Choice E: Encourage family members to stay with the client Family members can provide a familiar and reassuring presence, which can help orient the client and potentially reduce agitation and restlessness. They can also provide valuable information about the client’s normal behavior and any changes they have noticed.

Parameters to Monitor:

Choice A: Fall risk The client is attempting to get out of bed without assistance, which increases the risk of falls4. Monitoring the client’s mobility and implementing fall prevention strategies is crucial.

Choice E: Sleep-wake cycle The client has been awake most of the night, indicating a disruption in the sleep-wake cycle5. Monitoring the client’s sleep patterns can provide information about the progression of delirium and the effectiveness of interventions.

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Correct Answer is A

Explanation

Choice A: Discussing childhood memories during group therapy
Discussing childhood memories is a core component of reminiscence therapy. This therapeutic approach involves recalling and sharing past experiences, which can help older adults improve their mood, enhance their sense of identity, and reduce feelings of isolation. By discussing childhood memories, clients can connect with each other and their own past, fostering a sense of community and continuity. This strategy is particularly effective in group settings where shared experiences can lead to meaningful conversations and emotional support.

Choice B: Making a unit calendar to promote orientation
While making a unit calendar can be beneficial for promoting orientation and helping clients keep track of time, it is not a primary strategy of reminiscence therapy. Reminiscence therapy focuses more on recalling and discussing past experiences rather than current orientation. Therefore, while useful, this strategy does not align directly with the goals of reminiscence therapy.

Choice C: Encouraging thought-stopping to block undesirable thoughts
Thought-stopping is a cognitive-behavioral technique used to interrupt negative or unwanted thoughts. It is not typically associated with reminiscence therapy, which aims to encourage the recall of past experiences, both positive and negative, to help clients process their emotions and memories. Blocking thoughts would counteract the purpose of reminiscence therapy, which is to explore and reflect on past experiences.

Choice D: Playing board games with other clients to enhance cognition
Playing board games can be a valuable activity for enhancing cognition and social interaction among older adults. However, it is not specifically a strategy of reminiscence therapy. Reminiscence therapy focuses on discussing and reflecting on past experiences rather than engaging in cognitive games. While board games can be beneficial, they do not fulfill the primary objectives of reminiscence therapy.

A. Place the client in restraints B. Obtain a prescription for haloperidol. C. Take the client to the seclusion room. D. Verbally de-escalate the client.

Correct Answer is D

Explanation

Choice A reason:
Placing a client in restraints is a restrictive intervention that should be used only as a last resort when all other less invasive options have been exhausted. Restraints can increase agitation and have potential physical and psychological harm. The use of restraints must comply with institutional policies and legal regulations, which often require that less restrictive measures be attempted first.

Choice B reason:
Haloperidol is an antipsychotic medication used to treat acute psychosis and severe agitation. However, it is associated with side effects such as extrapyramidal symptoms and QT prolongation, which can lead to serious cardiac events. Medication should not be the first-line intervention for agitation unless the client poses an immediate threat to themselves or others, and non-pharmacological measures have failed.

Choice C reason:
Seclusion is another restrictive intervention that involves placing a client in a specially designed room to manage behavioral disturbances. It is used to ensure safety when a client is extremely violent or agitated. However, evidence suggests that seclusion does not provide long-term benefits in treating symptoms or reducing aggression and can be a negative experience for the client. It should not be the first intervention used.

Choice D reason:
Verbal de-escalation is the process of using calm language, listening skills, and empathy to help a client gain control of their behavior. It is a non-restrictive, first-line intervention that can prevent the situation from escalating. Techniques include communicating effectively, offering clear explanations, and providing realistic options. This approach helps maintain safety and supports the therapeutic relationship between the nurse and the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement?

Correct Answer is A

Explanation

A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?

Correct Answer is D

Explanation

A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?

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?

The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400. Exhibits Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)

A nurse is contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?

A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?

A nurse is collecting data from a client who reports drinking alcoholic beverages daily but has not consumed alcohol in the last 24 hours. Which of the following findings should the nurse identify as a manifestation of alcohol withdrawal?

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?