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A nurse is collecting data from an older adult client who was admitted with heart failure.
The nurse should report which of the following findings to the provider as an indication of delirium? .

Consistent state of depression

Fluctuating level of orientation.

Demonstrates obsessive behaviors.

Family report of gradual memory loss.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A consistent state of depression is not indicative of delirium, but rather a mood disorder.

Choice B rationale:

Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.

Choice C rationale:

Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.

Choice D rationale:

Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.

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Correct Answer is D

Explanation

Choice A rationale:

This statement is generalizing the client’s feelings, which can lead to a lack of individualized care.

Choice B rationale:

This statement is not acknowledging the client’s feelings of grief, which can lead to a lack of trust in the nurse-client relationship.

Choice C rationale:

This statement is self-disclosing personal information, which can lead to boundary violations in the nurse-client relationship.

Choice D rationale:

This statement is encouraging the client to express their feelings, which can help in the grieving process.

A. Administer acyclovir. B. Administer lorazepam. C. Initiate 1:1 supervision. D. Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential Provider Prescription	Expected or Unexpected?	Explanation
Administer acyclovir.	Unexpected	Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause.
Administer lorazepam.	Expected	Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention.
Initiate 1:1 supervision.	Expected	The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.	Expected	The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration.

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A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium? .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?.

Correct Answer is D

Explanation

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

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A nurse is collecting data from an older adult client who was admitted with heart failure.
The nurse should report which of the following findings to the provider as an indication of delirium? .