The nurse is assessing an elderly client who has become confused since admission to the hospital two days ago.
Which assessment should the nurse complete first?
Oxygen saturation measurement.
Review of current medications.
Intake and output last 24 hours.
Use of hearing aids or glasses.
The Correct Answer is A
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“I feel uncomfortable praying with you, but I will find someone who won’t feel that way.” This statement by the nurse would best meet the client’s spiritual needs because it acknowledges the nurse’s own boundaries and feelings while also respecting the client’s request and finding a way to fulfill it.
Some possible explanations for why the other choices are wrong are:
Choice A is wrong because it does not address the client’s request to pray together and it assumes that the client wants a Bible without asking.
Choice B is wrong because it implies that the nurse does not want to pray with the client and that the client’s visitors would be more suitable for this task, which could make the client feel rejected or unsupported.
Choice C is wrong because it directly rejects the client’s request and discloses the nurse’s personal beliefs, which could create a sense of disconnection or conflict between the nurse and the client.
Correct Answer is ["A","C"]
Explanation
These interventions help the client to cope with stress by enhancing their social support and teaching them skills to manage stressors.
Choice B is wrong because sedative hypnotics may cause dependence and do not address the underlying causes of stress.
Choice D is wrong because discussing factors that contribute to stress may increase the client’s anxiety and does not provide any solutions.
The normal range for coping is to use adaptive strategies that reduce stress and promote well-being.
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