A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?
"Delirium has an abrupt onset."
"Delirium does not affect a client's sleep cycle."
"Delirium has a slow progression."
"Delirium does not affect a client's perception of her environment."
The Correct Answer is A
Choice A reason:
Delirium is a sudden and acute change in mental status characterized by confusion, disorientation, altered consciousness, and other cognitive disturbances. It has an abrupt onset and is often related to an underlying medical condition, medication, or other factors such as infections or metabolic imbalances.
Choice B reason:
Delirium can indeed affect a client's sleep cycle. It often disrupts sleep patterns and can lead to sleep disturbances
Choice C reason:
Delirium does not have a slow progression. It is typically characterized by a rapid and fluctuating course, and it can develop over hours to days.
Choice D reason:
Delirium does affect a client's perception of their environment. Clients with delirium may experience hallucinations, paranoia, and other alterations in perception. They may be unable to accurately interpret or interact with their surroundings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The client has expressed a lack of understanding about the procedure, which indicates that they may not have received sufficient information or clarification. It is important to notify the provider so they can ensure the client fully understands the procedure before giving informed consent.
Choice B reason:
The nurse should provide basic information and answer questions within their scope, but detailed explanations about the procedure are best provided by the provider who is performing the surgery.
Choice C reason:
While brochures can be helpful, they do not replace the need for direct, clear communication with the healthcare provider about the specific details of the surgery.
Choice D reason:
An incident report is not necessary in this context as the situation is related to informed consent and not an error or safety issue.
Correct Answer is B, C, E, D, A
Explanation
B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.
C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.
E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.
D.Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort
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