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Which of the following actions should the nurse take? Select all that apply.

Maintain a well-lit environment.

Reorient the client often.

Request that the client have the same caregivers with every shift.

Ask the client's partner to stay with the client as much as possible.

Request that the client's family bring the client's eyeglasses from home.

Provide the client with information about what to expect during their care

Write the full date on the client's whiteboard:

Acknowledge the client’s feelings

Answer and Explanation

Correct Answer : A,B,C,D,E,F,G,H

The client is demonstrating acute delirium in the ICU, likely related to severe infection (possible postoperative wound infection progressing to sepsis), hypoxia risk, and multiple sensory impairments such as visual and hearing loss. Delirium is characterized by fluctuating confusion, disorientation, hallucinations, and altered attention. Management focuses on identifying and treating the underlying cause while providing a calm, structured, and orienting environment. Nursing interventions prioritize safety, reorientation, sensory support, and emotional reassurance.

Rationale:
A. Maintaining a well-lit environment helps reduce visual misinterpretations and hallucinations commonly seen in delirium. Adequate lighting decreases shadows that may be misinterpreted as threatening stimuli, especially in clients with visual impairment. A stable, well-lit setting promotes orientation and reduces anxiety and agitation.

B. Reorienting the client often is essential because delirium involves fluctuating confusion and disorganized thinking. Frequent reminders of time, place, and situation help reduce disorientation and anxiety. Consistent reorientation supports cognitive grounding and helps the client regain awareness of reality.

C. Requesting that the client have the same caregivers with every shift promotes consistency and familiarity, which helps reduce confusion and agitation. Continuity of care decreases environmental stressors and improves trust in caregivers. This is especially beneficial in delirious clients who struggle with frequent changes in staff and routine.

D. Asking the client's partner to stay with the client as much as possible provides comfort, familiarity, and emotional reassurance. Family presence can reduce agitation, improve orientation, and help calm hallucinations or delusional thinking. Familiar voices and presence are grounding factors in delirium management.

E. Requesting that the client's family bring eyeglasses from home addresses sensory deprivation, which can worsen delirium. Visual impairment increases misinterpretation of surroundings and contributes to hallucinations. Restoring vision improves environmental awareness and helps the client interpret reality more accurately.

F. Providing detailed information about what to expect during care is not appropriate during acute delirium because the client has impaired attention and cognition. Complex explanations may increase confusion and agitation rather than reduce it. Education is more appropriate once delirium resolves and cognition stabilizes.

G. Writing the full date on the client's whiteboard helps reinforce orientation to time, which is commonly impaired in delirium. Visual cues serve as constant reminders of current temporal context and support cognitive reorientation. This simple environmental modification is an effective non-pharmacological intervention.

H. Acknowledging the client’s feelings is therapeutic because it validates emotional distress without reinforcing hallucinations or delusions. This helps reduce anxiety and agitation while maintaining trust between the nurse and client. Emotional support is a key component of delirium management alongside reorientation and safety measures.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

The client presents with severe hypertension, heavy proteinuria, hyperreflexia, edema, and abnormal liver function tests, all consistent with worsening preeclampsia with severe features. These findings indicate widespread endothelial dysfunction and vasospasm affecting multiple organ systems, including the brain and placenta. The most dangerous complications in this condition are those that threaten maternal neurologic stability and fetal oxygenation, particularly eclampsia (seizures) and placental abruption.

Rationale for correct choices:

• Placental abruption: Severe preeclampsia significantly increases the risk of placental abruption due to impaired uteroplacental perfusion and vasospasm of maternal blood vessels. This can lead to premature separation of the placenta from the uterine wall, resulting in acute fetal hypoxia and maternal hemorrhage. The client’s severe hypertension and proteinuria indicate endothelial injury, which contributes to placental instability. Abruption is a major obstetric emergency that can rapidly compromise both maternal and fetal outcomes.

• Seizures: Seizures represent progression from severe preeclampsia to eclampsia, which is one of the most dangerous complications of hypertensive disorders in pregnancy. The client already demonstrates neurological irritability, evidenced by severe headache and hyperreflexia (4+ reflexes). Cerebral vasospasm and edema increase the risk of seizure activity. Without timely magnesium sulfate therapy, the client is at high risk for convulsions, cerebral hemorrhage, and maternal/fetal death.

Rationale for incorrect choices:

• Heart failure: Although severe preeclampsia involves increased vascular resistance and fluid shifts, heart failure is not the most immediate or characteristic complication in this scenario. The client’s lungs are not showing signs of pulmonary edema, and oxygen saturation remains normal. While fluid overload can occur in severe cases, neurological and placental complications are more urgent threats. Heart failure is not the highest priority risk based on the current findings.

• Cervical insufficiency: Cervical insufficiency is a structural cervical problem that leads to painless cervical dilation and preterm birth, typically unrelated to hypertensive disorders. It is not associated with proteinuria, hypertension, or end-organ dysfunction. The client’s presentation is vascular and systemic in nature, not structural cervical failure. Therefore, this complication does not apply to the current clinical picture.

• Hypoglycemia: There is no evidence of abnormal glucose regulation in this client, with a normal glucose level of 85 mg/dL. Preeclampsia does not typically cause hypoglycemia as a primary complication. The primary risks are vascular, neurological, and placental rather than metabolic glucose disturbances. Hypoglycemia is not a relevant or expected complication in this scenario.

A. Nystagmus B. Astigmatism C. Client reports sharp pain D. Loss of central vision

Correct Answer is D

Explanation

Age-related macular degeneration is a progressive retinal disorder affecting the macula, the portion of the retina responsible for central detailed vision. Degeneration of macular photoreceptor cells leads to impaired visual acuity, difficulty reading, and reduced ability to recognize faces or perform fine visual tasks. Peripheral vision is typically preserved, but central vision progressively deteriorates. Nurses caring for clients with this condition should recognize characteristic visual changes associated with retinal damage.

Rationale:
A. Nystagmus is an involuntary rhythmic eye movement commonly associated with neurologic disorders, vestibular dysfunction, or congenital visual impairment. It is not a characteristic finding of macular degeneration because the disorder primarily affects retinal central vision rather than ocular motor control. Therefore, this finding would not be expected.

B. Astigmatism is a refractive error caused by irregular curvature of the cornea or lens, leading to blurred vision at multiple distances. It is unrelated to retinal degeneration and does not result from macular damage. Macular degeneration affects the retina itself rather than the refractive structures of the eye.

C. Sharp eye pain is not typically associated with macular degeneration. The condition is generally painless because retinal degeneration does not stimulate pain receptors. Sudden or severe ocular pain would suggest another disorder such as glaucoma, corneal injury, or acute inflammation rather than Macular degeneration.

D. Loss of central vision is the hallmark finding of macular degeneration due to progressive deterioration of the macula. Clients commonly report blurred or distorted central vision, difficulty reading, or dark spots in the center of their visual field. Peripheral vision is often maintained despite significant central visual impairment.

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Which of the following actions should the nurse take? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse is continuing to assist with the care of the client. Drag words from the choices below to fill in each blank in the following sentence. The complications that the client is at greatest risk for developing are dropdownanddropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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