The nurse is caring for an older adult client who is experiencing delirium. Which of the following should be the priority action by the nurse?

Administer diazepam.

Obtain a medical history.

Start intravenous fluids.

Raise 3 of the 4 side rails of the bed.

Answer and Explanation

The Correct Answer is B

A. Administer diazepam: This is not a first-line treatment for delirium and could exacerbate confusion or sedation, potentially worsening delirium.

B. Obtain a medical history: Delirium is often caused by underlying medical conditions such as infections, electrolyte imbalances, or medication side effects. Obtaining a medical history is crucial for identifying and treating the underlying cause, making it the priority action.

C. Start intravenous fluids: While IV fluids might be necessary in cases of dehydration or electrolyte imbalances, identifying the underlying cause of delirium through medical history is more urgent.

D. Raise 3 of the 4 side rails of the bed: This action may help prevent falls but does not address the underlying cause of delirium. Moreover, the use of side rails can sometimes increase the risk of injury or entrapment.

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Correct Answer is D

Explanation

A. Promoting rehabilitation directed toward achievement of each individual's maximum level of functioning: This describes tertiary prevention, which focuses on reducing the impact of an ongoing illness that has lasting effects by helping people manage long-term, complex health problems.

B. Services aimed at reducing the residual defects that are associated with severe and persistent mental illness: This is also an aspect of tertiary prevention, which involves managing chronic conditions to prevent further deterioration.

C. Services aimed at reducing the incidence of mental disorders within the population: This describes primary prevention, which involves efforts to prevent the onset of illness before it occurs, typically through community health initiatives and education.

D. Interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness: This correctly defines secondary prevention, which involves early detection and treatment of disease to halt progression and reduce the severity and duration of the condition.

A. Chronic pain B. Low self-esteem C. Euphoria D. Irritability E. Insomnia

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

Explanation

A. Chronic pain: Depression can manifest as physical symptoms, including chronic pain, in adolescents.

B. Low self-esteem: This is a common feature of depression, where individuals may feel worthless or inadequate.

C. Euphoria: Euphoria is more associated with manic episodes, not depression.

D. Irritability: Depression in adolescents often presents with irritability rather than sadness.

E. Insomnia: Sleep disturbances, including insomnia, are common symptoms of depression.

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The nurse is caring for an older adult client who is experiencing delirium. Which of the following should be the priority action by the nurse?

Nursing Test Bank

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