The nurse is caring for a client with a disturbance in thought process who is disoriented and aggressive. What nursing action may produce further agitation?

Being present without speaking

Presenting the reality of the situation

Allowing the client freedom in a confined area

Speaking in slow, brief sentences

Answer and Explanation

The Correct Answer is B

A. Being present without speaking: Remaining quietly present can be grounding and non-threatening to disoriented clients. It helps establish a calming environment and builds trust without increasing sensory input.
B. Presenting the reality of the situation: Confronting a disoriented or psychotic client with reality may escalate agitation and aggression. Challenging their perception can feel threatening and lead to increased resistance or hostility.
C. Allowing the client freedom in a confined area: Providing limited autonomy in a safe space can reduce feelings of powerlessness. It supports de-escalation by allowing the client some control while ensuring safety.
D. Speaking in slow, brief sentences: Clear, simple communication helps reduce cognitive overload in disoriented clients. It decreases anxiety and supports comprehension, making it a key strategy in managing agitation.

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Correct Answer is D

Explanation

A. Blood specimen for electrolyte studies: Electrolyte studies help assess dehydration but do not confirm a Cryptosporidium infection. This test monitors fluid and electrolyte balance, not the presence of parasites.
B. Sputum specimen for acid fast bacillus: This test is used to detect tuberculosis or other mycobacterial infections. Cryptosporidium affects the gastrointestinal tract, not the respiratory system.
C. Urine specimen for culture and sensitivity: Urine cultures detect urinary tract infections but are unrelated to gastrointestinal pathogens like Cryptosporidium. This specimen is not appropriate for diagnosing diarrhea caused by parasites.
D. Stool specimen for ova and parasites: Cryptosporidium is a protozoan parasite that infects the intestines. Stool analysis for ova and parasites is the correct diagnostic approach to identify this organism in clients with AIDS and severe diarrhea.

A. Fever, sore throat, and chills B. Nausea and vomiting C. Intolerance to heat and rash D. Diarrhea, diaphoresis, and fever

Correct Answer is A

Explanation

A. Fever, sore throat, and chills: These are classic signs of infection and are especially concerning in leukopenia, where the body’s ability to fight infections is compromised due to a low white blood cell count. Prompt recognition is critical for early intervention.
B. Nausea and vomiting: While these may be side effects of many medications, they are not specific indicators of leukopenia. They reflect gastrointestinal irritation rather than immunosuppression.
C. Intolerance to heat and rash: These symptoms are more consistent with thyroid dysfunction or allergic reactions, not leukopenia. They do not suggest a compromised immune response.
D. Diarrhea, diaphoresis, and fever: Though fever can be a sign of leukopenia-related infection, diarrhea and diaphoresis are nonspecific symptoms and may relate to other systems or drug side effects. Fever, sore throat, and chills are more indicative of infection due to leukopenia.

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The nurse is caring for a client with a disturbance in thought process who is disoriented and aggressive. What nursing action may produce further agitation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?

Correct Answer is D

Explanation

A client is taking a medication that has the side effect of depressing the hematopoietic system. What signs of leukopenia should the nurse monitor for while the client is taking this drug?

Correct Answer is A

Explanation

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