What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?

Reduce environmental stimuli

Suction the oropharynx

Assess pulse oximetry

Administer oxygen

Answer and Explanation

The Correct Answer is A

A. Restlessness and agitation in nonverbal clients can often be exacerbated by environmental factors such as noise, bright lights, or unfamiliar surroundings. By reducing environmental stimuli, such as dimming lights, minimizing noise, and providing a calm atmosphere, the nurse can help alleviate agitation and promote a more comfortable environment for the client.

B. Suctioning the oropharynx is not typically the first action unless there is a clear indication that airway obstruction or secretion management is contributing to the client's agitation. It is important to first assess whether there are signs of respiratory distress or airway compromise before performing suctioning.

C. Assessing pulse oximetry is important for monitoring oxygen saturation levels, especially if there are concerns about respiratory distress or inadequate oxygenation. However, it is not typically the first action when a client is restless and agitated unless there are specific indications or signs suggesting respiratory compromise.

D. Administering oxygen may be necessary if there are signs of hypoxia or respiratory distress contributing to the client's agitation. However, without assessing the client's oxygenation status first, administering oxygen as the initial action may not address the underlying cause of agitation.

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

Explanation

A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.

E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.

B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.

C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.

D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.

A. Both are accompanied by changes in level of consciousness. B. Memory is affected equally in both diseases. C. Only delirium is reversible. D. The progression of both diseases is slow.

Correct Answer is C

Explanation

C. Delirium is often reversible once the underlying cause is identified and treated (e.g., correcting electrolyte imbalances, managing infections, discontinuing medications contributing to delirium). With appropriate intervention, the mental status can improve, and the individual can return to their baseline cognitive function.

A. Dementia, on the other hand, is a chronic, progressive syndrome that primarily affects memory, thinking, behavior, and the ability to perform everyday activities. It does not typically cause acute changes in consciousness.

B. Memory impairment is a hallmark feature of dementia, especially in the early stages. In contrast, delirium primarily affects attention, awareness, and cognition acutely, with memory impairment being variable and not a defining feature.

D. Delirium develops rapidly, often over hours to days, in response to an acute medical condition, medication change, or other factors. It is characterized by a fluctuating course and can resolve once the underlying cause is managed.

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What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

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

Explanation

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Correct Answer is C

Explanation

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