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 C
Explanation
A. "I just don't remember what I did this morning." This statement reflects an inability to recall the events of the morning, which is a common symptom in Alzheimer's disease but does not constitute confabulation. It simply indicates memory loss.
B. "This morning, this morning, this morning..." Repetition of words or phrases can indicate a language or communication issue often seen in Alzheimer's disease but is not an example of confabulation. It may reflect confusion or perseverance.
C. "It was good. The Queen of England visited me there." Confabulation involves the creation of false memories or statements to fill in gaps in memory. The client's statement about the Queen of England visiting is a fabricated or distorted memory and is an example of confabulation. This choice is correct.
D. "Snip, snap. Take a nap." This phrase is nonsensical and may indicate disorganized thinking or speech, which can occur in Alzheimer's disease, but it is not an example of confabulation. It does not fill a memory gap with a fabricated story. Therefore, this choice is incorrect.
Correct Answer is D
Explanation
A. Financial exploitation: Financial exploitation involves the illegal or improper use of an elder's funds, property, or assets. It does not involve the direct infliction of physical or psychological harm .
B. Emotional abuse: Emotional abuse involves inflicting psychological harm through verbal or non-verbal acts, such as intimidation, humiliation, or isolation. It directly impacts the elder’s emotional and mental well-being.
C. Neglect: Neglect is the failure to provide necessary care or assistance, leading to harm or distress. It may not involve active infliction of harm but results in harm due to omission of care.
D. Physical abuse: Physical abuse involves the intentional infliction of bodily harm through actions such as hitting, shaking, or restraining. It directly results in physical injury and can also lead to psychological harm. This choice is correct
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