Which assessment finding would the nurse expect in a patient who has been diagnosed with hypoactive delirium?

Hyperactivity and agitation.

Hallucinations and delusions.

Lethargy and reduced alertness.

Combative behavior and shouting.

Answer and Explanation

The Correct Answer is C

Choice A reason: Hyperactivity and agitation characterize hyperactive delirium, not hypoactive, which involves lethargy. Reduced alertness is typical, making this incorrect, as it describes the opposite presentation of hypoactive delirium in the nurse’s assessment of the patient’s mental status.

Choice B reason: Hallucinations and delusions are more common in hyperactive or mixed delirium, not hypoactive, which features withdrawal. Lethargy is expected, making this incorrect, as it does not align with the typical findings in hypoactive delirium during the nurse’s evaluation.

Choice C reason: Lethargy and reduced alertness define hypoactive delirium, with patients appearing withdrawn or sleepy. This aligns with delirium assessment criteria, making it the correct finding the nurse would expect in a patient diagnosed with hypoactive delirium in a clinical setting.

Choice D reason: Combative behavior and shouting indicate hyperactive delirium, not hypoactive, which is marked by lethargy. Reduced alertness is the correct finding, making this incorrect, as it misrepresents the subdued presentation of hypoactive delirium in the nurse’s patient assessment.

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Correct Answer is B

Explanation

Choice A reason: Showering and walking the next day are appropriate post-thyroidectomy activities, promoting mobility without strain. Expecting yellow drainage indicates a misunderstanding, as it suggests infection, making this correct and incorrect for needing further teaching, as it aligns with recovery expectations.

Choice B reason: Yellow drainage from the incision suggests infection, not a normal post-thyroidectomy expectation, indicating a need for further teaching. Normal drainage, if any, is minimal and serosanguinous, making this the correct choice, as it reflects a misconception requiring clarification in the patient’s recovery education.

Choice C reason: Avoiding heavy lifting is accurate, as it prevents strain on the surgical site post-thyroidectomy. Yellow drainage is an incorrect expectation, making this correct and incorrect for needing teaching, as it aligns with proper recovery restrictions to ensure healing and safety.

Choice D reason: Avoiding excessive neck extension is appropriate to protect the incision and promote healing post-thyroidectomy. Yellow drainage is a misconception, making this correct and incorrect for needing teaching, as it reflects proper understanding of activity limitations during the recovery period.

A. Patients must be screened for any recent history of gastrointestinal (GI) bleeding. B. tPA must be given within 8 hours of the onset of signs of ischemic stroke. C. tPA is a high-risk drug which requires a two-nurse verification. D. Patients with embolic strokes are not candidates for tPA. E. Closely monitor the patient’s vital signs and neurologic status.

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

Explanation

Choice A reason: Screening for recent GI bleeding is critical, as tPA increases bleeding risk, contraindicating its use in such patients. This aligns with stroke treatment protocols, making it a correct intervention the nurse must ensure before administering tPA for acute ischemic stroke.

Choice B reason: tPA is effective within 4.5 hours of stroke onset, not 8 hours, for most patients. This is incorrect, as it exceeds the therapeutic window, unlike screening for bleeding or monitoring, which are essential interventions for safe tPA administration in stroke care.

Choice C reason: tPA, a high-risk thrombolytic, requires two-nurse verification to ensure accurate dosing and administration, reducing errors. This aligns with medication safety protocols, making it a correct intervention the nurse must follow when administering tPA for an acute ischemic stroke.

Choice D reason: Embolic strokes are candidates for tPA if within the time window and no contraindications exist. This is incorrect, as it wrongly excludes a valid stroke type, unlike monitoring or bleeding screening, which are critical for safe tPA administration.

Choice E reason: Close monitoring of vital signs and neurologic status is essential post-tPA to detect complications like hemorrhage or worsening stroke. This aligns with stroke care guidelines, making it a correct intervention the nurse must implement during tPA administration for ischemic stroke.

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Which assessment finding would the nurse expect in a patient who has been diagnosed with hypoactive delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who had a thyroidectomy tells the nurse, “I need to restrict my activities and not return to work for 4 weeks.” Which statement indicates a need for further teaching?

Correct Answer is B

Explanation

The head computed tomography (CT) result indicates no bleeding in the brain and the neurologist diagnoses an acute ischemic stroke and orders tPA. Select the appropriate interventions for tPA administration. (Select all that apply)

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

Explanation

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Which assessment finding would the nurse expect in a patient who has been diagnosed with hypoactive delirium?

What test results would indicate hyperthyroidism?

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