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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Sitting the client at a 90-degree angle (upright position) helps prevent orthostatic hypotension and cardiovascular complications in clients with spinal cord injuries by improving venous return and cardiac output.
Choice B Rationale: Administering 2000 liters of fluid is an inappropriate intervention, and the volume mentioned is excessive.
Choice C Rationale: Applying compression socks may help prevent deep vein thrombosis (DVT) but does not address cardiovascular complications related to sitting position.
Choice D Rationale: Maintaining blood pressure exactly at 110/80 is not a feasible or appropriate intervention.
Correct Answer is D
Explanation
Choice A Rationale: Linking the pain to nasal stuffiness is not an accurate explanation of trigeminal neuralgia.
Choice B Rationale: Hypoglycemia is not typically related to trigeminal neuralgia.
Choice C Rationale: Releasing catecholamines with infection or stress is not the primary cause of trigeminal neuralgia.
Choice D Rationale: Pain is often due to stimulation of the affected nerve by pressure and temperature. This is a more accurate and relevant explanation for trigeminal neuralgia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today