An older adult who was discharged from the hospital two days ago is brought to the emergency department because of the sudden onset of confusion.
After the patient is stabilized, which action by the nurse is most important?
Assess for the use of nutritional supplements.
Verify if the patient takes new medications.
Evaluate the patient for gait abnormalities.
Perform a dementia screening test.
The Correct Answer is B
Choice A rationale
While nutritional supplements can interact with medications or cause side effects, a sudden onset of confusion two days post-discharge strongly suggests an acute physiological or pharmacological cause. New or changed medications or an infection are much more probable immediate causes for acute mental status change in a recently hospitalized older adult.
Choice B rationale
New medications or changes in dosage often cause acute adverse effects in older adults due to age-related physiological changes that impair drug metabolism (hepatic) and excretion (renal), leading to higher plasma concentrations and potential toxicity. This is a common and critical cause of acute confusion (delirium) following hospital discharge, making it the most important initial assessment.
Choice C rationale
Gait abnormalities are relevant for assessing fall risk or chronic neurological conditions but are not the most immediate or essential step after stabilization for acute confusion. While gait assessment is important, it is secondary to identifying and reversing the immediate cause of the delirium.
Choice D rationale
A dementia screening test assesses for chronic cognitive decline. Sudden onset of confusion is characteristic of delirium, an acute and potentially reversible medical emergency, not dementia. The priority is to identify and treat the underlying acute cause (e.g., medication toxicity, infection), not screen for chronic disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Type I hypersensitivity, or immediate hypersensitivity, is IgE-mediated and typically presents rapidly with symptoms like urticaria (hives), angioedema, bronchospasm, and hypotension due to massive mast cell degranulation and histamine release. While it can cause hypotension, the classic triad of chills, lower back pain, and profound hypotension/tachycardia is not primarily characteristic of this type during a blood transfusion.
Choice B rationale
Type II hypersensitivity, a cytotoxic reaction, is the classic mechanism for an acute hemolytic transfusion reaction (AHTR). The patient's pre-existing antibodies (IgG or IgM) bind to antigens on the transfused red blood cells (RBCs), leading to complement activation. This massive intravascular hemolysis releases inflammatory mediators, causing the characteristic triad of chills, back pain (due to renal damage/ischemia), hypotension, and tachycardia.
Choice C rationale
Type III hypersensitivity is an immune-complex reaction where soluble antigens and antibodies (IgG or IgM) form complexes that deposit in tissues, often manifesting as vasculitis, arthritis, or nephritis. While it can occur in delayed transfusion reactions, it is not the primary mechanism for the immediate, severe AHTR symptoms described, which are dominated by cell lysis.
Choice D rationale
Type IV hypersensitivity is a delayed, cell-mediated reaction involving T-lymphocytes and macrophages. It typically takes 24 to 72 hours to manifest and is responsible for contact dermatitis or the tuberculin skin test. The acute, life-threatening symptoms observed within minutes of a transfusion reaction exclude this slower, non-antibody-mediated response.
Correct Answer is ["A","D","E","F"]
Explanation
Choice A rationale
Scanning the patient's ID band confirms the identity of the patient using two identifiers, a crucial step in the "five rights" of medication administration to ensure the drug is given to the correct individual and to integrate with electronic health records.
Choice B rationale
Calling the patient's name three times is not a standard, evidence-based procedure for medication safety; standard protocol requires using at least two forms of patient identification (e.g., name, date of birth, medical record number).
Choice C rationale
Taking a screenshot of a medication order is a deviation from proper documentation and is not an essential action; the order must be viewed and verified within the secure electronic health record (EHR) or patient chart.
Choice D rationale
Assessing the patient prior to administration is essential to establish a baseline, determine if the medication is still appropriate based on the patient's current condition (e.g., vital signs, lab values), and check for contraindications.
Choice E rationale
Verifying medication allergies is a mandatory safety step to prevent life-threatening anaphylactic or hypersensitivity reactions, aligning with the "right patient" and "right drug" components of medication safety.
Choice F rationale
Performing hand hygiene (handwashing or alcohol-based hand rub) is necessary immediately before patient contact and medication preparation to comply with infection control guidelines and prevent the transmission of microorganisms.
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