A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following in the health record should the nurse identify as a cause of this disorder?

Seasonal allergies

History of GERD

Benzodiazepines

Completed antibiotics 10 days ago

Answer and Explanation

The Correct Answer is C

Choice A Reason: Seasonal allergies are not a cause of delirium, but a common condition that affects the respiratory system and causes symptoms such as sneezing, runny nose, itchy eyes, or coughing.

Choice B Reason: History of GERD is not a cause of delirium, but a chronic condition that affects the digestive system and causes symptoms such as heartburn, regurgitation, chest pain, or difficulty swallowing.

Choice C Reason: Benzodiazepines are a cause of delirium, especially in older adults or those with cognitive impairment. Benzodiazepines are a class of drugs that act on the central nervous system and cause sedation, relaxation, and reduced anxiety. However, they can also impair memory, attention, orientation, and judgment, and lead to confusion, agitation, hallucinations, or delusions.

Choice D Reason: Completed antibiotics 10 days ago are not a cause of delirium, but a treatment for bacterial infections. Antibiotics can have side effects such as nausea, diarrhea, rash, or allergic reactions, but they do not cause delirium unless they are toxic or interact with other medications.

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Correct Answer is B

Explanation

Choice A Reason: Hemorrhage is not a complication of an acute spinal cord injury, but rather a possible cause of it. Hemorrhage can occur due to trauma or rupture of blood vessels in or around the spinal cord, leading to compression and damage of the nerve tissue.

Choice B Reason: This is the correct choice. Spinal shock is a complication of an acute spinal cord injury that occurs within minutes to hours after the injury. It is characterized by loss of sensation, motor function, reflexes, and autonomic function below the level of injury. It is caused by transient disruption of nerve conduction and synaptic transmission in the spinal cord.

Choice C Reason: Apoptosis is not a complication of an acute spinal cord injury, but rather a cellular process that occurs after it. Apoptosis is programmed cell death that occurs in response to injury or stress. It can lead to further loss of neurons and glial cells in the spinal cord over time.

Choice D Reason: Neurogenic shock is a complication of an acute spinal cord injury that occurs within hours to days after the injury. It is characterized by hypotension, bradycardia, and peripheral vasodilation due to loss of sympathetic tone and unopposed parasympathetic activity. It is caused by disruption of autonomic pathways in the spinal cord.

A. 36 percent B. 54 percent C. 27 percent D. 18 percent E. 9 percent

Correct Answer is A

Explanation

Choice A Reason: This is the correct choice. Using the rule of nines, each arm accounts for 9 percent of TBSA, each leg accounts for 18 percent of TBSA, and front and back are equally divided. Therefore, burns on both sides of both arms and legs equal to (9 + 9) x 2 + (18 + 18) x 2 = 36 percent of TBSA.

Choice B Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 54 percent. To get 54 percent of TBSA, one would have to add burns on both sides of head and neck (9 percent), chest (9 percent), and abdomen (9 percent).

Choice C Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 27 percent. To get 27 percent of TBSA, one would have to subtract burns on both sides of one leg (18 percent).

Choice D Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 18 percent. To get 18 percent of TBSA, one would have to divide burns on both sides of both arms and legs by two.

Choice E Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 9 percent. To get 9 percent of TBSA, one would have to divide burns on both sides of both arms and legs by four.

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A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following in the health record should the nurse identify as a cause of this disorder?

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A client arrives to the emergency department after falling from a ladder. The client has a loss of sensation and flaccid paralysis. Which of the following complications of an acute spinal cord injury does the nurse suspect?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is A

Explanation

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