An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia.
Which of the following is the best reason for the assessment findings?

Mood disorder.

Sensory deprivation.

Anxiety.

Cerebral vascular accident (CVA).

Answer and Explanation

The Correct Answer is B

Sensory deprivation is a condition in which a person experiences a lack of sensory input or stimulation.

This can result from isolation, confinement, or loss of sensory function. Sensory deprivation can cause psychological and physiological changes, such as irritability, confusion, paranoia, hallucinations, depression, anxiety, and cognitive impairment.

Choice A is wrong because mood disorder is a general term for a group of mental health conditions that affect a person’s emotional state, such as depression, bipolar disorder, or anxiety disorder. Mood disorder is not likely to be caused by isolation precautions for C diff.

Choice C is wrong because anxiety is a feeling of nervousness, worry, or fear that interferes with daily functioning. Anxiety can be triggered by stress, trauma, or other factors, but it is not a direct consequence of isolation precautions for C diff.

Choice D is wrong because cerebral vascular accident (CVA), also known as stroke, is a sudden interruption of blood flow to the brain that causes neurological damage. CVA can cause symptoms such as weakness, numbness, slurred speech, vision loss, or confusion, but it is not related to isolation precautions for C diff.

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Correct Answer is A

Explanation

This is because coughing can indicate aspiration of the feeding into the lungs, which can lead to pneumonia and other serious complications. Aspiration is reported in up to 89% of patients receiving nasogastric tube feeding.

Therefore, the nurse should prioritize assessing the client for signs of aspiration and ensuring proper tube placement.

Choice B is wrong because mild abdominal cramps are a common side effect of nasogastric tube feeding and do not require immediate intervention unless they are severe or persistent.

Choice C is wrong because high-pitched bowel sounds are normal and indicate peristalsis and digestion.

They do not indicate a problem with the tube feeding.

Choice D is wrong because one to two soft bowel movements per day are desirable and indicate adequate nutrition and hydration.

They do not indicate a problem with the tube feeding.

Normal ranges for gastric residual volume are less than 200 mL for adults and less than 100 mL for children. Normal ranges for pH of gastric aspirate are 1 to 5.

A. Reduced muscle mass. B. Decreased renal function. C. Slowed gastrointestinal motility. D. Thinning of the layers of the skin.

Correct Answer is B

Explanation

This is because older adults have a reduced ability to excrete drugs and their metabolites through the kidneys, which can lead to drug accumulation and toxicity. Decreased renal function can also affect the pharmacokinetics and pharmacodynamics of many drugs, altering their absorption, distribution, metabolism, and elimination.

Choice A is wrong because reduced muscle mass does not directly affect drug metabolism or clearance, although it may affect the volume of distribution of some drugs that are highly protein-bound or lipophilic.

Choice C is wrong because slowed gastrointestinal motility does not increase the risk of adverse drug events in older adults, although it may affect the rate and extent of drug absorption.

Choice D is wrong because thinning of the layers of the skin does not affect drug metabolism or clearance, although it may increase the risk of skin infections or injuries.

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An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia. Which of the following is the best reason for the assessment findings?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia.
Which of the following is the best reason for the assessment findings?