Goals and desired outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on what?
Identifying stressors negatively affecting self
Demonstrating motor responses to noxious stimuli
Returning to premorbid levels of function
Exerting control over responses to perceptual distortions
The Correct Answer is C
A. Identifying stressors negatively affecting self may be useful in some mental health conditions but is less relevant for delirium caused by fever and dehydration. Delirium is primarily an acute, reversible condition that is related to physiological causes, such as infection or dehydration, rather than emotional or psychological stressors.
B. Demonstrating motor responses to noxious stimuli refers to a neurophysiological response and is not the primary goal in the treatment of delirium. In delirium, the focus is on addressing the underlying cause (e.g., fever, dehydration), managing symptoms, and restoring cognitive function, rather than evaluating motor responses.
C. Returning to premorbid levels of function is the most appropriate and relevant goal for a patient experiencing delirium due to fever and dehydration. Since delirium in this context is often reversible once the underlying causes (such as dehydration and fever) are addressed, the desired outcome is to help the patient recover and return to their previous level of functioning and cognitive baseline. This is the primary goal of treatment for delirium caused by an acute, reversible condition.
D. Exerting control over responses to perceptual distortions could be a helpful goal in managing patients with psychotic or more chronic cognitive conditions, but delirium primarily affects acute cognitive states. While delirium can involve perceptual distortions, the main focus in treating delirium is addressing the underlying causes and promoting recovery to the patient's previous cognitive state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Avoidance of physical contact is not the priority intervention for a patient with delirium. While you may want to be gentle and avoid unnecessary contact, the priority is to ensure the patient's safety and provide support in a way that helps prevent injury, confusion, or further agitation.
B. Application of wrist and ankle restraints is not recommended unless absolutely necessary for patient safety (such as if the patient is at risk of harming themselves or others). Restraints should be a last resort and only used when all other interventions have failed.
C. Careful observation and supervision is the priority nursing intervention for a patient with delirium. Due to fluctuating levels of consciousness and altered perception, the patient is at risk for injury (e.g., falling, wandering). Close observation helps ensure the patient's safety and provides an opportunity to intervene if the condition worsens.
D. High level of sensory input is generally not recommended for patients with delirium, as it may increase confusion and agitation. Instead, providing a calm, quiet environment with minimal distractions is typically preferred.
Correct Answer is B
Explanation
A. Exelon (rivastigmine) is an FDA-approved medication for Alzheimer's disease. It is a cholinesterase inhibitor that works by increasing levels of acetylcholine, a neurotransmitter important for memory and learning .
B. Risperdal (risperidone) is not approved by the FDA for the treatment of Alzheimer's disease. It is an atypical antipsychotic medication primarily used to treat schizophrenia and bipolar disorder. While it may be prescribed off-label for managing certain behavioral symptoms in Alzheimer's patients, its use in this context carries significant risks, including increased mortality in elderly patients with dementia-related psychosis .
C. Namenda (memantine) is an FDA-approved medication for moderate to severe Alzheimer's disease. It is an NMDA receptor antagonist that helps regulate glutamate activity, which is involved in learning and memory .
D. Aricept (donepezil) is an FDA-approved medication for all stages of Alzheimer's disease. It is a cholinesterase inhibitor that increases levels of acetylcholine in the brain .
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