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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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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

  • Vision (Blurred)

    • Interpretation: Potential worsening condition
    • Rationale: Blurred vision can be a sign of lithium toxicity. Despite the lithium level improving, this symptom indicates that neurotoxicity may still be present.

  • Lithium Level (1.2 mEq/L)

    • Interpretation: Potential improvement
    • Rationale: The lithium level has decreased from 1.8 mEq/L (toxic) to 1.2 mEq/L, which is within the therapeutic range (0.6-1.2 mEq/L). This indicates that treatment to lower lithium toxicity is effective.

  • Urine Output (40 mL/hr)

    • Interpretation: Potential improvement
    • Rationale: A urine output of 40 mL/hr is within the acceptable range (normal is greater than 30 mL/hr), suggesting that kidney function is adequate and not compromised by lithium toxicity.

  • Mucous Membranes (Pale, Dry)

    • Interpretation: Potential worsening condition
    • Rationale: Pale, dry mucous membranes suggest dehydration, which can increase the risk of lithium toxicity and negatively affect overall health.

  • Vital Signs (BP 88/50 mm Hg, Pulse 96/min)

    • Interpretation: Potential worsening condition
    • Rationale: The drop in blood pressure from 130/84 mm Hg to 88/50 mm Hg indicates hypotension. This could be related to dehydration or lithium toxicity, and it requires follow-up as the condition is deteriorating.

Correct Answer is D

Explanation

Choice A rationale:
Cardiac enzymes do not identify the location of the MI, they are biomarkers that indicate heart muscle injury.
Choice B rationale:
Cardiac enzyme tests do not provide information about the heart’s structure or the mobility of the heart valves. That’s typically assessed using imaging studies like an echocardiogram.
Choice C rationale:
Cardiac enzymes do not assist in diagnosing the presence of pulmonary congestion. They are specific to heart muscle damage.
Choice D rationale:
Cardiac enzymes, such as troponin and creatine kinase, rise when there is damage to the heart muscle, such as in an MI. Therefore, these tests help determine the degree of damage to the heart tissues.

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