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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:
"New dressing applied as prescribed; no drainage on old dressing. “This entry provides clear and concise information about the action taken (applying a new dressing as prescribed) and the assessment of the old dressing (no drainage present). It accurately reflects the dressing change process and the status of the wound.
Choice B reason:
"Client premedicated with MSO, sub-prior to dressing change." This entry is incorrect because it provides information about the client being premedicated, but it doesn't specifically address the dressing change or the pressure injury.
Choice C reason:
"The wound seems clean and does not appear to be infected." While this entry provides an assessment of the wound's cleanliness and potential infection, it lacks specific details about the dressing change itself.
Choice D reason:
"No changes noted to the wound from previous nursing notes." This entry focuses on comparing the wound to previous notes but doesn't provide information about the current dressing change or assessment.

A. Develop a plan for the client to integrate the change into her lifestyle. B. Assist the client in setting goals to make the change. C. Recommend small changes for the client to make to change her behavior over time. D. Present information about the benefits of quitting smoking.

Correct Answer is D

Explanation

A. Develop a plan for the client to integrate the change into her lifestyle: Developing a plan for integrating change into one's lifestyle is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the focus is on considering change rather than developing a detailed plan.
B. Assist the client in setting goals to make the change: Setting specific goals is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the client is not yet ready to commit to specific goals.
C. Recommend small changes for the client to make to change her behavior over time: During the contemplation stage of health behavior change, clients are considering making a change but are not yet committed to taking immediate action. This is also more suitable for the preparation or action stages.
D. In the contemplation stage, the client is aware of the problem and is considering making a change but has not yet committed to action. Providing information about the benefits can help the client move toward the next stage of change.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?

Correct Answer is A

Explanation

A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?

Correct Answer is D

Explanation

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