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 D

Explanation

Choice A reason:
Mixing medications together in a single syringe is not recommended unless specifically approved by a pharmacist or healthcare provider, as some medications may interact with each other and cause adverse effects or reduced efficacy.
Choice B reason:
Medications should not be combined with the formula in the feeding bag. This can alter the effectiveness of both the medications and the feeding formula.
Choice C reason:
Flushing the NG tube with 5 mL of sterile water is generally not enough. The tube should be flushed with a sufficient amount of water (usually 15-30 mL) before and after administering medications to ensure that the medications are delivered properly and to prevent clogging.
Choice D reason:
Each medication should be diluted with sterile water to ensure it can pass through the NG tube without clogging and to facilitate proper absorption.

A. Percuss all four quadrants of the abdomen to measure sound quality. B. Provide adequate lighting to inspect the abdomen. C. Listen to the abdominal arteries using the bell of a stethoscope. D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen. E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.

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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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 preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B, C, E, D, A

Explanation

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