A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

A Overdose

B Acute dementia

C Substance abuse comorbidity

D Acute delirium

Answer and Explanation

The Correct Answer is D

Choice A Rationale: Documenting an overdose is premature without further assessment and evidence.

Choice B Rationale: Acute dementia is not typically diagnosed based on rapidly fluctuating moods alone, and it may not be appropriate for this situation.

Choice C Rationale: While substance abuse comorbidity may be present, it does not fully capture the client's current presentation.

Choice D Rationale: Documenting acute delirium is appropriate in this case. The client's symptoms, including rapidly fluctuating moods and delusions, are indicative of acute delirium, which can be related to substance withdrawal or other medical issues.

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

Explanation

Choice A Rationale: Asking the spouse what she knows about dementia care options is a good starting point to assess her knowledge and provide information and resources, and empowering her to make informed decisions.

Choice B Rationale: Suggesting placement into a long-term care facility should not be the first option but can be explored if necessary, based on the client's condition and the caregiver's needs.

Choice C Rationale: Teaching the spouse about adult day care as a possible respite is a way of offering support and relief for the caregiver, who may experience stress and burnout from the constant demands of caring for a patient with AD.

Choice D Rationale: Suggesting that the spouse consult with the physician for antianxiety drugs is not helpful, as it may imply that the spouse's feelings are abnormal or that she needs medication to cope.

Choice E Rationale: Offering ideas for ways to distract or redirect the patient is not relevant to the spouse's needs, as it does not address her exhaustion and worry.

A. A Unscrew the pins from the cervical tongs B. B Ask the client to sit on the edge of the bed C. C Gather supplies and at least 3 other people D. D Remove the straps from the halo vest

Correct Answer is C

Explanation

Choice A Rationale: Unscrewing the pins from the cervical tongs is not the best first action for bathing a client with a spinal cord injury.

Choice B Rationale: Asking the client to sit on the edge of the bed may not be appropriate or safe without proper assistance and equipment.

Choice C Rationale: The best first action is to gather supplies and at least 3 other people. Bathing a client with a spinal cord injury can be complex and may require additional assistance for safety and comfort.

Choice D Rationale: Removing the straps from the halo vest is not the first step in the bathing process and may not be necessary.

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A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take at this time? Select All that Apply

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

Explanation

A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

Correct Answer is C

Explanation

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which is the best action by the nurse?

A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

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A nurse is preparing a care plan for a client with a spinal cord injury. Which of the following is the highest priority for the nurse to implement?

A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching?

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?