An elderly client presents to the emergency room with a family member. The family member reports that the elderly client has been vomiting and not eating or drinking for 2 days. This morning the elderly client became confused, which is new. The nurse knows the elderly client probably has which of the following?
Delirium
New onset Alzheimer's disease
New onset Huntington's disease
New onset Parkinson's disease
The Correct Answer is A
A. Delirium is an acute, temporary state of confusion, often caused by factors such as dehydration, infection, or metabolic disturbances. In this case, the elderly client’s confusion following vomiting and not eating or drinking for 2 days suggests that dehydration or an underlying illness is likely causing the delirium.
B. Alzheimer's disease is a progressive, degenerative condition that leads to chronic memory loss and cognitive decline. It does not typically cause sudden confusion, as seen in this case.
C. Huntington's disease is a genetic neurodegenerative disorder that causes motor dysfunction and cognitive decline. It does not present suddenly with confusion in an elderly client.
D. Parkinson's disease is a progressive neurological disorder that primarily affects motor function, causing tremors, rigidity, and bradykinesia. It does not typically present with sudden confusion or the symptoms described in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Unstable blood pressure can occur with damage to the hypothalamus or pituitary, but it is more commonly associated with other neurological conditions. While blood pressure may fluctuate, it is not the most direct result of pituitary or hypothalamic damage.
B. Diabetes insipidus is the correct answer. The pituitary gland secretes antidiuretic hormone (ADH), which helps regulate water balance. Damage to the pituitary or hypothalamus can lead to a deficiency of ADH, causing diabetes insipidus, which is characterized by excessive thirst and urination.
C. Diabetes mellitus is a condition related to insulin production and blood sugar regulation, typically caused by pancreatic issues, not damage to the pituitary or hypothalamus.
D. Altered respiratory rate can occur with brain injury, but it is more commonly associated with damage to the brainstem rather than the hypothalamus or pituitary.
Correct Answer is D
Explanation
A. The client should not sit upright in a chair for prolonged periods (such as 4 hours at a time) immediately following spinal fusion, as this could place excessive strain on the surgical site. The client should be assisted to sit upright for short periods and be repositioned regularly.
B. Clear drainage on the spinal dressing could indicate cerebrospinal fluid leakage, which is a concern following spinal surgery. The nurse should expect minimal to no drainage, and if clear fluid is observed, it should be reported immediately.
C. Elevating the client's legs when lying on his side may not be necessary unless specifically ordered by the healthcare provider. In general, the client should maintain proper body alignment and avoid any positions that strain the surgical site.
D. Log rolling is a critical intervention for spinal fusion patients to prevent twisting of the spine. The nurse should assist the client in log rolling every 2 hours to maintain spinal alignment and prevent injury to the surgical site.
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