A 70year old client diagnosed with a hemorrhagic stroke was admitted 1 day ago. His

medical history includes hypertension, osteoarthritis, and type 2 diabetes. He has right sided

paralysis, garbled speech, and a weak cough reflex. This morning he is restless. Vital signs are Blood Pressure 160/80, pulse 110, respirations 24, oxygen saturation 90% Which of the following Interventions will the nurse take to avoid complications? Select all that apply

Select All that Apply)

Apply oxygen

Monitor blood pressure

Implement seizure precautions

Provide oral fluids

Turn the client twice each shift

Answer and Explanation

Correct Answer : A,B,C,F

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Free Nursing Study Resources

Correct Answer is A

Explanation

Identify the underlying cause. This is correct because delirium is a reversible condition that is often caused by an underlying medical problem, such as infection, medication, or dehydration.

Identifying and treating the cause can help resolve the delirium and prevent further complications.

Tell the client that hallucinations are not real. This is incorrect because it can increase the client's anxiety and confusion. The nurse should acknowledge the client's feelings and perceptions, but not reinforce or argue with them.

Speak slowly and clearly. This is incorrect because it is not the best first action. While speaking slowly and clearly can help communicate with the client, it does not address the root cause of the delirium.

Request the assistance of physical therapy. This is incorrect because it is not relevant to the question. Physical therapy may be helpful for some clients with delirium, but it is not a priority intervention.

A. Document the time the seizure began. B. Turn the client's head to the side. C. Check the client's motor strength. D. Loosen the clothing around the client's waist.

Correct Answer is B

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

According to the ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?

Correct Answer is A

Explanation

A nurse is in a client's room when the client begins having a tonicclonic seizure. Which of the following actions should the nurse take first?

Correct Answer is B

A physician tells the family of a client involved in a motorvehicle accident that the client sustained a coupcontrecoup injury. Which of the following statements by the nurse indicates an understanding of this type of traumatic brain injury?

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

A nurse is monitoring the vitals of a client who has a traumatic brain injury. Which of the following indicate that the client is in stage 3 of increased Intracranial pressure? Select all that apply (Select All that Apply.)

A client is extremely drowsy, minimally responsive, and has a difficult time following commands. With vigorous stimulation the client awakens but quickly falls back asleep. What level of consciousness does this describe?

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of Increased Intracranial pressure (ICP)?

A client arrives to the emergency department after a motor vehicle accident. The nurse records the following Glasgow Coma scores: E3, V2, M1. What is the best first action for the nurse to take.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?