Which are would be a priority of care for a patient who is being admitted to the hospital and its demonstrating signs of delirium?

Safety precaution

Oxygenation

Pain management

Infection

Answer and Explanation

The Correct Answer is A

A.   The priority in managing delirium is ensuring the patient's safety, as delirium increases the risk of falls, self-harm, and other dangerous behaviors. Close monitoring and protective measures are essential.
B.   Oxygenation is important but not the first priority unless the patient shows signs of hypoxia or respiratory distress.
C.   Pain management should be considered, but it is secondary to addressing the safety risks associated with delirium.
D.   Infection should be investigated, but the immediate concern in delirium is safety due to the altered mental state.

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Correct Answer is C

Explanation

A. The client is unable to make vocal sound would be more consistent with a verbal response score of 1.
B. The client is unconscious is not correct, as a GCS score of 13 indicates they are not in a deep coma.
C. A GCS score of 3 for eye opening indicates that the patient responds to verbal stimuli (eye-opening to speech), a score of 5 for best verbal response indicates they can speak but not necessarily coherently, and a 5 for best motor response indicates purposeful movement, like following commands.
D. The client can follow simple motor commands would typically reflect a motor response score of 6, not

A. Shivering B. Seizures C. Dehydration D. Burns

Correct Answer is A

Explanation

A. Shivering is a common response to cold therapy (such as a hypothermia blanket) as the body attempts to maintain its core temperature. This can increase metabolic demands and oxygen consumption, which should be closely monitored.
B. Seizures are not typically associated with the use of hypothermia blankets unless there are underlying conditions that predispose to them.
C. Dehydration could occur with any prolonged therapy but is not the immediate concern with hypothermia blankets.
D. Burns are rare but could occur if the hypothermia blanket is not properly managed. Shivering is a more immediate concern.

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Which are would be a priority of care for a patient who is being admitted to the hospital and its demonstrating signs of delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is C

Explanation

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

Correct Answer is A

Explanation

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