Mr. G is calling out "Nurse!" When you arrive in his room, he tells you to be careful of the snake in the corner. You do not see anything in the corner. Mr. G is experiencing an:
Illusion.
Attention-getting behavior.
Hallucination.
Delusion.
The Correct Answer is C
Choice A reason: An illusion is a misinterpretation of a real external stimulus, which is not the case here as there is no snake.
Choice B reason: Attention-getting behavior is a possibility, but given that Mr. G is specifically referencing a snake that isn't there, it suggests a hallucination.
Choice C reason: A hallucination is a sensory perception in the absence of external stimuli, which fits Mr. G's description of seeing a snake that isn't there.
Choice D reason: A delusion is a firmly held false belief; while Mr. G may have this, the immediate experience he's describing is a hallucination, not a delusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Applying gentle pressure on the exposed organs is not recommended as it can cause further damage.
Choice B reason: Having the client lie supine with legs straight is part of the correct positioning, but it does not address the need to protect the exposed organs.
Choice C reason: Suctioning secretions from the wound bed is not the immediate priority and can be harmful to the exposed tissues.
Choice D reason: Covering the area with saline-soaked sterile dressings is the correct intervention to keep the organs moist and reduce the risk of organ damage until surgical repair can be performed.
Correct Answer is B
Explanation
Choice A reason: Notifying the physician is important, but it is not the immediate action to take. The nurse should first assess the patient's condition before contacting the physician.
Choice B reason: Evaluating the distal pulses is the correct action because it provides information on the blood flow to the extremities, which is crucial for patients with PAD.
Choice C reason: Having the patient lie in bed with a pillow under the knees is not recommended for PAD patients as it can decrease blood flow to the lower extremities.
Choice D reason: Covering the patient with a blanket may provide comfort, but it does not address the underlying issue of impaired blood flow in PAD.
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