A nurse is reinforcing teaching with a client who is scheduled for a thoracentesis. Which of the following information should the nurse include in the teaching?

"You will be placed leaning over a bedside table during the procedure."

"You will not be able to eat or drink four hours prior to the procedure."

"You will receive moderate sedation prior to the procedure."

"You will need to lie on your affected side for 30 minutes following the procedure."

Answer and Explanation

The Correct Answer is A

Teaching for a client undergoing a thoracentesis focuses on positioning, procedure expectations, and safety measures used to remove pleural fluid from the pleural space. A thoracentesis is typically performed to diagnose or treat pleural effusion by inserting a needle into the pleural cavity while the client maintains a position that maximizes intercostal space exposure. Proper positioning is essential to reduce risk of lung injury and ensure accurate fluid removal.

Rationale:
A. Leaning over a bedside table is the correct position for a Thoracentesis because it maximizes intercostal space widening and moves the scapulae outward. This position allows safe needle insertion above the rib to avoid neurovascular structures. It also improves access to pleural fluid accumulation, especially in the posterior lung fields.

B. Fasting for four hours prior is not typically required for thoracentesis because it is usually performed under local anesthesia rather than general sedation. Unlike surgical procedures requiring airway management, oral intake restrictions are generally unnecessary unless sedation is planned. Therefore, this instruction is not standard for this procedure.

C. Moderate sedation is not routinely administered for thoracentesis. The procedure is typically done with local anesthetic to numb the insertion site while the client remains awake and cooperative. Sedation may increase risk of respiratory depression in clients who already have compromised lung function.

D. Lying on the affected side after thoracentesis is not recommended as standard practice. Post-procedure positioning is generally upright or in a position that promotes lung expansion and monitoring for complications such as pneumothorax. Lateral positioning is not required unless specifically prescribed for drainage or comfort.

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Correct Answer is B

Explanation

Delirium is an acute, fluctuating disturbance in attention, cognition, and consciousness that develops over a short period of time. It is commonly triggered by an underlying medical condition, medication effect, or metabolic imbalance. Older adults and hospitalized clients are especially vulnerable. Identifying and treating the underlying cause is essential for reversing symptoms and preventing complications such as injury or prolonged cognitive impairment.

Rationale:
A. Amyloid plaque is associated with chronic neurodegenerative processes such as Alzheimer’s disease, which leads to gradual cognitive decline rather than the acute, fluctuating changes seen in delirium. While dementia increases vulnerability to delirium, amyloid plaques themselves are not an acute precipitating risk factor.

B. Urinary tract infection is a correct risk factor because infections are one of the most common reversible causes of delirium, especially in older adults. Infections such as Urinary tract infection can trigger systemic inflammation and metabolic changes that affect brain function, leading to acute confusion, restlessness, and disorientation.

C. High cholesterol is a long-term cardiovascular risk factor but is not directly associated with the acute onset of delirium. It contributes to chronic vascular disease over time rather than causing sudden cognitive changes. Therefore, it is not considered an immediate precipitating factor.

D. Hypersomnia refers to excessive sleepiness and is more commonly associated with sleep disorders, depression, or medication effects. It is not a known direct risk factor for delirium, which is characterized by acute confusion and fluctuating levels of consciousness rather than increased sleep duration.

A. Brief Psychiatric Rating Scale B. Mental Status Examination C. Abnormal Involuntary Movement Scale D. Patient Health Questionnaire-9

Correct Answer is C

Explanation

Clients taking long-term antipsychotic medications for conditions such as schizophrenia are at risk of developing extrapyramidal symptoms, including tardive dyskinesia. Tardive dyskinesia is a late-onset movement disorder characterized by repetitive, involuntary movements, often involving the face, tongue, and extremities. Early detection is essential because symptoms may become irreversible if not identified promptly. Nurses use standardized screening tools to monitor for abnormal motor activity in clients receiving antipsychotic therapy.

Rationale:
A. The Brief Psychiatric Rating Scale is used to assess psychiatric symptoms such as depression, anxiety, hallucinations, and overall psychopathology severity. It does not specifically evaluate involuntary motor movements associated with antipsychotic adverse effects. Therefore, it is not appropriate for detecting tardive dyskinesia.

B. The Mental Status Examination evaluates cognitive function, orientation, mood, thought processes, and perception. While it helps assess overall mental functioning in clients with Schizophrenia, it does not specifically screen for extrapyramidal side effects such as tardive dyskinesia.

C. The Abnormal Involuntary Movement Scale is the correct tool because it is specifically designed to detect and measure the severity of involuntary movements associated with long-term antipsychotic use. It assesses facial, oral, and limb movements to identify early signs of tardive dyskinesia, allowing for timely intervention and medication adjustment.

D. The Patient Health Questionnaire-9 is a screening tool used to assess the severity of depressive symptoms. It is not designed to evaluate motor disorders or medication side effects related to antipsychotic therapy. Therefore, it is not appropriate for identifying tardive dyskinesia.

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A nurse is reinforcing teaching with a client who is scheduled for a thoracentesis. Which of the following information should the nurse include in the teaching?

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