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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 C

Explanation

Choice A rationale:

Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.

Choice B rationale:

Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.

Choice C rationale:

Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.

Choice D rationale:

While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.

A. Alcohol use disorder B. Currently married. C. Access to guns in the home. D. Sibling history of suicide. E. Terminal liver cancer.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Alcohol use disorder is a risk factor for suicide. Alcohol can increase impulsivity and decrease inhibitions, which can lead to suicidal behaviors.

Choice B rationale:

Being currently married is generally considered a protective factor against suicide, not a risk factor.

Choice C rationale:

Access to lethal means, such as guns in the home, is a significant risk factor for suicide.

Choice D rationale:

A family history of suicide, including a sibling history of suicide, is a risk factor for suicide.

Choice E rationale:

Terminal illnesses, such as liver cancer, can increase feelings of hopelessness and despair, which are risk factors for suicide.

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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 dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?.

Correct Answer is C

Explanation

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.) .

Correct Answer is ["A","C","D","E"]

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? .