The spouse of an older client experiencing delirium is at the client's bedside. The nurse is providing an update to the spouse regarding the client's plan of care. Which of the following responses by the spouse indicates a need for further teaching?
"l brought an updated list of all the medications he takes at home to help you and the doctors determine what the cause of this could be."
"l notified our family members that they should not come visit for a while, until they are better."
"l am not worried. This sort of thing happens all the time to us 'old people.'"
"l am trying to stay positive. I know that most people return to normal, but it is hard to see them like this."
None
None
The Correct Answer is C
Answer: C. "I am not worried. This sort of thing happens all the time to us 'old people.'"
A. "I brought an updated list of all the medications he takes at home to help you and the doctors determine what the cause of this could be."
This response indicates understanding and proactive involvement in the client’s care. An updated medication list is crucial in evaluating potential causes of delirium, as certain medications or interactions can contribute to changes in mental status.
B. "I notified our family members that they should not come visit for a while, until they are better."
This statement reflects an understanding of the need for a calm environment for the client experiencing delirium. Reducing stimuli and visitors can help the client focus on recovery. It indicates the spouse is aware of the potential impact of social interactions on the client’s condition.
C. "I am not worried. This sort of thing happens all the time to us 'old people.'"
This response indicates a need for further teaching. It reflects a possible misunderstanding of delirium as a normal part of aging, which can be dismissive of the seriousness of the condition. Delirium is often a sign of underlying medical issues and should be treated with concern and urgency. Clients and their families need to understand that delirium is not a typical or benign occurrence and requires appropriate evaluation and intervention.
D. "I am trying to stay positive. I know that most people return to normal, but it is hard to see them like this."
This statement indicates a hopeful attitude while acknowledging the difficulty of the situation. It shows understanding that recovery is possible and reflects the spouse's emotional processing of the situation. Maintaining a positive outlook can be beneficial for both the client and the family during recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Answer: B, C, E
Correct Answer is B
Explanation
A. Severe myopia: Severe myopia refers to nearsightedness and is not typically associated with Meniere's disease. Myopia affects vision but is unrelated to the characteristic symptoms of Meniere's disease.
B. Vertigo: Vertigo is a hallmark symptom of Meniere's disease. It is characterized by a sensation of spinning or dizziness, often accompanied by nausea, vomiting, and imbalance. Vertigo episodes in Meniere's disease can be severe and debilitating, significantly impacting the individual's quality of life.
C. Anosmia: Anosmia refers to a loss of sense of smell and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to vestibular dysfunction, such as vertigo, rather than olfactory disturbances.
D. Photopsia: Photopsia refers to the perception of flashing lights or visual disturbances and is not a characteristic manifestation of Meniere's disease. Visual disturbances may occur in certain conditions affecting the eyes or visual pathways but are not typically associated with Meniere's disease, which primarily affects the inner ear and vestibular system.
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