A young man with malaria spikes a temperature of 105°F (40.5°C) and begins to hallucinate. How should the nurse assess this?

Delirium

Psychotic break

Possible stroke

Anxiety disorder

Answer and Explanation

The Correct Answer is A

A. Delirium: Delirium is characterized by acute confusion, disorientation, and altered mental status often due to severe infection or high fever.

B. Psychotic break: While hallucinations are a symptom, a psychotic break is generally a chronic mental health condition rather than an acute response to infection.

C. Possible stroke: Stroke symptoms usually involve sudden onset of neurological deficits rather than fever and hallucinations.

D. Anxiety disorder: Anxiety disorders do not typically cause such high fevers or acute hallucinations.

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Correct Answer is D

Explanation

A. Shock is a concern immediately after the burn injury due to fluid loss but is less likely after the initial 72 hours.
B. Hemorrhage is not a common cause of death following burns unless associated with a traumatic injury.
C. Respiratory arrest: Respiratory complications are a concern, but infection remains the leading cause of death post-72 hours.
D. Infection: After the first 72 hours, infection becomes the most common cause of burn-related deaths due to the compromised skin barrier and potential for sepsis.

A. Assist with reality orientation. B. Coach in deep breathing. C. Assist with rational thought. D. Aid in decision making.

Correct Answer is B

Explanation

A. Assist with reality orientation: Reality orientation is more suitable for psychotic disorders or delirium.

B. Coach in deep breathing: Deep breathing helps to calm the patient and reduce the physiological symptoms of a panic attack.

C. Assist with rational thought: Rational thought is difficult to achieve during a panic attack; calming measures are more appropriate.

D. Aid in decision making: Decision-making assistance is not practical during a panic attack when the patient is highly distressed.

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A young man with malaria spikes a temperature of 105°F (40.5°C) and begins to hallucinate. How should the nurse assess this?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for which most common cause of burn-related deaths?

Correct Answer is D

Explanation

When a patient is experiencing a panic attack, how should the nurse best assist the patient?

Correct Answer is B

Explanation

The nurse has staged a pressure injury that has a shallow crater with a dry pink wound bed in which way?

Which will the nurse examine when assessing a patient for tinea corporis?

When should family members of a stroke victim expect to see some of the neurologic involvement disappear?

A patient is preparing to receive electroconvulsive therapy. The nurse caring for this patient identifies which patient problem as the highest priority?

What is the most common cause of dementia?

While creating a methadone protocol for a patient rehabilitating from heroin addiction, the nurse explains that the patient will take methadone for what length of time?

The nurse concludes that a significant goal of the care plan for an alcoholic patient has been met when the patient makes which statement?