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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Medication side effects: Certain medications can cause cognitive impairment that mimics dementia, but this condition is often reversible if the medication is adjusted or discontinued.
B. Hypothyroidism: Hypothyroidism can lead to cognitive impairment that may be reversible with appropriate thyroid hormone replacement therapy.
C. Vitamin B12 deficiency: Deficiency in vitamin B12 can cause cognitive deficits that are often reversible with supplementation.
D. Multiple small brain infarcts: This condition, often associated with vascular dementia, usually leads to permanent brain damage and is typically not reversible.
Correct Answer is D
Explanation
A. Family conflict: Family conflict can contribute to suicidal ideation, but the presence of an active psychiatric disorder is a more direct risk factor.
B. Homosexuality: Sexual orientation itself is not a risk factor for suicide, but discrimination and lack of acceptance related to sexual orientation can contribute to risk.
C. Availability of firearms: Access to firearms increases the lethality of suicide attempts but is not as significant as the presence of an active psychiatric disorder.
D. Active psychiatric disorder: This is the correct answer. Conditions such as depression, bipolar disorder, and substance use disorders significantly increase the risk of suicide in adolescents.
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