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 B

Explanation

Face the client while speaking and ask them to verify understanding. This intervention would help the client to read the nurse’s lips and confirm the message.

It would also show respect and empathy for the client’s condition.

Choice A is wrong because using exaggerated mouth and hand movements when speaking can be distracting and insulting to the client.

It can also distort the words and make them harder to understand.

Choice C is wrong because standing in front of a light when speaking to the client can create glare and make it difficult for the client to see the nurse’s face.

Touching the client to be sure they know where you are can be startling and unnecessary if the client is not visually impaired.

Choice D is wrong because obtaining an interpreter for sign language is inappropriate unless the client knows sign language.

Not all hearing-impaired clients use sign language, and some may prefer other methods of communication.

A. Anxiety. B. Acute pain. C. Knowledge deficit. D. Nausea and vomiting.

Correct Answer is B

Explanation

This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.

Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.

Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.

Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.

Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.

Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.

Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.

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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?

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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?