The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.

Exhibits

Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Limit visitation from the client’s family.

Reorient the client to person, place, and time frequently.

Rotate nursing staff daily.

Approach the client slowly.

Maintain a low-stimulation environment.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Limiting visitation from the client’s family may not be beneficial as the presence of familiar people can often help reorient and calm the client. Family members can provide comfort and reassurance, which can be particularly helpful for a client experiencing delirium.
Choice B reason: Reorienting the client to person, place, and time frequently is a recommended intervention for patients with delirium. This can help reduce confusion and agitation in clients with delirium.
Choice C reason: Rotating nursing staff daily could potentially increase confusion for the client, as continuity of care and familiar faces can be beneficial in managing delirium. Therefore, this option is not recommended.
Choice D reason: Approaching the client slowly is a recommended intervention for patients with delirium. Given the client’s agitation and confusion, it’s important to approach them in a non-threatening manner to avoid escalating their distress.
Choice E reason: Maintaining a low-stimulation environment is a recommended intervention for patients with delirium. A calm and quiet environment can help reduce agitation and confusion in clients with delirium.

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Correct Answer is C

Explanation

Choice A reason:
The statement "Have you noticed that your taste has decreased?" is not a common side effect of olanzapine. Olanzapine is an atypical antipsychotic used to treat schizophrenia and bipolar disorder. Common side effects include weight gain, drowsiness, and increased appetite, but changes in taste are not typically reported.

Choice B reason:
The statement "Have you noticed a ringing in your ears?" is also not a common side effect of olanzapine. Tinnitus (ringing in the ears) is not associated with olanzapine use. More common side effects include dizziness, dry mouth, and constipation.

Choice C reason:
The statement "Have you noticed an increase in thirst?" is the correct response. Olanzapine can cause hyperglycemia (high blood sugar), which can lead to increased thirst and urination. Monitoring for signs of hyperglycemia is important in clients taking olanzapine.

Choice D reason:
The statement "Have you noticed unintentional weight loss?" is not typical for clients taking olanzapine. In fact, weight gain is a more common side effect of olanzapine, along with increased appetite.

A. Sudden onset of confusion B. Hallucinations C. Agitation D. Current medical diagnosis

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}

Explanation

a. Sudden onset of confusion

Delirium: Yes. Sudden onset of confusion is a common symptom of delirium, which can develop over hours or days.

Alzheimer’s disease: No. Alzheimer’s disease typically involves a gradual decline in memory, thinking, and reasoning skills.

b. Hallucinations

Delirium: Yes. Hallucinations are a symptom of delirium.

Alzheimer’s disease: Yes. While not as common, hallucinations can occur in later stages of Alzheimer’s disease.

c. Agitation

Delirium: Yes. Agitation is a common symptom of delirium.

Alzheimer’s disease: Yes. Agitation can occur in Alzheimer’s disease, particularly in the middle and later stages.

d. Current medical diagnosis

Delirium: Yes. The client’s current diagnosis is delirium secondary to a urinary tract infection and dehydration.

Alzheimer’s disease: No. The client’s current diagnosis does not indicate Alzheimer’s disease.

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The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415. Exhibits Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a history from a client who has been taking olanzapine to treat schizophrenia. Which of the following questions should the nurse ask the client?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}

Explanation

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The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415. Exhibits Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.

Exhibits

Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.