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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 Most Likely Experiencing:

Delirium

Explanation: The client has acute confusion, disorganized thinking, restlessness, incoherent speech, and altered sleep-wake cycle—all classic signs of delirium. The sudden onset (starting the previous evening) and fever (38.6°C) suggest a potential underlying cause, such as infection or dehydration.

Actions to Take:

Monitor the client's fluid intake and output.

Explanation: The client has severe fluid imbalance (250 mL intake vs. 2,500 mL output), leading to dehydration, which can contribute to delirium. Monitoring intake and output is critical for managing hydration status.

Encourage family members to stay with the client.

Explanation: Familiar faces can help reorient the client and reduce agitation. Delirium often improves with familiar environmental cues and reassurance.

Parameters to Monitor:

Sleep-wake cycle.

Explanation: Disrupted sleep patterns are a key symptom of delirium. Tracking sleep can help assess improvement or worsening of the condition.

Fall risk.

Explanation: The client is attempting to get out of bed without assistance, which puts them at high risk for falls. Close monitoring is essential to prevent injury.

Incorrect Choices and Explanations:

Request a prescription for benzodiazepine.

Why Incorrect? Benzodiazepines can worsen delirium, especially in older adults, by increasing confusion and fall risk.

Assist the client to identify coping skills.

Why Incorrect? Delirium is an acute medical condition, not a psychological disorder. The focus should be on treating the underlying cause, not psychological coping strategies.

Encourage the client to exercise.

Why Incorrect? The client is confused, weak, and at risk of falls. Exercise is not appropriate at this stage.

BUN level.

Why Incorrect? While kidney function (BUN) could be affected by dehydration, monitoring fluid balance directly (intake/output) is more immediate and relevant.

Weight loss.

Why Incorrect? While the client has refused to eat or drink, weight loss occurs over time, whereas the primary concern is acute dehydration and delirium.

Suicidal ideation.

Why Incorrect? There is no indication of suicidal thoughts. The confusion and agitation are more likely due to delirium than depression.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:
Increasing fluid intake can help replace cerebrospinal fluid lost during a lumbar puncture, which can alleviate a post-lumbar puncture headache.
Choice B rationale:
Elevating the head of the bed can actually worsen a post-lumbar puncture headache by increasing the loss of cerebrospinal fluid.
Choice C rationale:
While pain medication can provide temporary relief, it does not address the underlying cause of the headache.
Choice D rationale:
Darkening the room and closing the door can help reduce sensory stimulation, but it does not directly address the cause of the headache.

A. Hemorrhagic stroke. B. Thrombotic stroke. C. Embolic stroke. D. Transient ischemic attack (TIA).

Correct Answer is A

Explanation

Choice A rationale:
Hemorrhagic stroke is characterized by sudden, severe headache, vomiting, and a significant increase in blood pressure, all of which are present in the client. This type of stroke occurs when a weakened blood vessel ruptures and bleeds into the surrounding brain.
Choice B rationale:
Thrombotic stroke is caused by a clot that develops in a blood vessel within the brain. It typically presents with less severe symptoms and a gradual onset, not a sudden one.
Choice C rationale:
Embolic stroke is caused by a clot that travels to the brain from another part of the body. Like thrombotic stroke, it typically has a more gradual onset.
Choice D rationale:
Transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain. It usually lasts less than an hour and does not cause permanent damage.

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Incorrect Choices and Explanations:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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