The nurse has reviewed the nurses’ notes, provider’s note, and laboratory results at 0230.
For each client’s finding, specify if the finding is consistent with delirium or Alzheimer’s disease. Each finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row.
Sudden onset of confusion
Hallucinations
Agitation
Current medical diagnosis
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}
a. Sudden onset of confusion
Delirium: Yes. Sudden onset of confusion is a common symptom of delirium, which can develop over hours or days.
Alzheimer’s disease: No. Alzheimer’s disease typically involves a gradual decline in memory, thinking, and reasoning skills.
b. Hallucinations
Delirium: Yes. Hallucinations are a symptom of delirium.
Alzheimer’s disease: Yes. While not as common, hallucinations can occur in later stages of Alzheimer’s disease.
c. Agitation
Delirium: Yes. Agitation is a common symptom of delirium.
Alzheimer’s disease: Yes. Agitation can occur in Alzheimer’s disease, particularly in the middle and later stages.
d. Current medical diagnosis
Delirium: Yes. The client’s current diagnosis is delirium secondary to a urinary tract infection and dehydration.
Alzheimer’s disease: No. The client’s current diagnosis does not indicate Alzheimer’s disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Using short, simple sentences is an effective communication strategy for clients experiencing moderate anxiety. Anxiety can impair cognitive processing, making it difficult for clients to understand complex information. By using clear and concise language, the nurse can help the client better comprehend what to expect after the cardiac catheterization. This approach reduces the client's anxiety by providing information in a manageable format.
Choice B Reason:
Showing a 30-minute teaching video might be overwhelming for a client with moderate anxiety. While visual aids can be helpful, the length and complexity of the video could increase the client's anxiety rather than alleviate it. It is important to tailor the educational approach to the client's current emotional state, ensuring that the information is presented in a way that is easy to understand and not overwhelming.
Choice C Reason:
Providing detailed explanations can be counterproductive for a client with moderate anxiety. Detailed information might overwhelm the client, leading to increased anxiety and difficulty in processing the information. Instead, the nurse should focus on delivering key points in a clear and concise manner, ensuring that the client understands the most important aspects of the procedure and what to expect afterward.
Choice D Reason:
Avoiding questions is not an effective strategy for client education. Asking questions allows the nurse to assess the client's understanding and address any concerns or misconceptions. Engaging the client in a dialogue helps to build rapport and ensures that the client feels supported and informed. It is important to create an open and interactive environment where the client feels comfortable asking questions and expressing concerns.
Correct Answer is ["B","D","E","F","I","J"]
Explanation
The findings that require follow-up are:
Client brought to the ED by police after being found wandering on the street. This indicates a potential safety issue and could suggest confusion or other cognitive impairment.
Client able to provide identity to police, but not able to identify place or time. This could indicate confusion or disorientation, which requires further assessment.
Client confused and agitated. Confusion and agitation can be symptoms of many conditions, including infection, intoxication, or neurological issues.
Appearance is disheveled. This could suggest self-neglect or other social issues that need addressing.
Mucous membranes dry. Dry mucous membranes can be a sign of dehydration, which may require treatment.
During assessment, client states, “Can you ask that person to leave my room?” Client is pointing to an empty chair. This could suggest hallucinations or delusions, which require further mental health assessment.
Temperature: 38.6° C (101.5° F). This is a fever and could indicate an infection or other medical condition.
Heart rate: 104/min. This is a high heart rate (tachycardia) and could be due to fever, dehydration, stress, or other conditions.
Blood pressure: 158/96 mm Hg. This is high blood pressure (hypertension) and could be due to a variety of conditions, including stress, kidney disease, or cardiovascular disease.
The other findings (f, j, l) are within normal limits and do not require immediate follow-up, but should continue to be monitored. Please consult with a healthcare professional for a comprehensive assessment.
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