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 C
Explanation
Choice A reason:
The cephalic vein on the back of the right hand is incorrect because it might still involve the same arm as the mastectomy site, and it is important to avoid this side.
Choice B reason:
The radial vein on the left wrist is incorrect because it is not on the opposite side of the mastectomy and could increase the risk of lymphedema.
Choice C reason:
The basilic vein in the right antecubital fossa is the appropriate answer. When inserting an IV catheter for a client who has undergone a right mastectomy, it is generally advisable to avoid the arm on the same side as the mastectomy due to the risk of lymphedema and impaired lymphatic drainage. The basilic vein in the right antecubital fossa (the inner bend of the right elbow) would be a suitable choice in this case, as it is on the opposite side of the mastectomy.
Choice D reason:
The cephalic vein in the left distal forearm is on the same side as the mastectomy and should be avoided to reduce the risk of complications.
Correct Answer is B
Explanation
Choice A reason:
Powdered gloves are more likely to release latex particles into the air, which can increase the risk of exposure for a client with a latex allergy. Therefore, using non-powdered gloves is recommended.
Choice B reason:
Scheduling the client as the first surgical procedure of the day is the appropriate action because it can help minimize the risk of latex exposure. This is because latex particles released into the air during previous surgeries can settle in the surgical environment, increasing the risk for individuals with latex allergies. By scheduling the client's surgery as the first procedure, the likelihood of exposure to residual latex particles is reduced.
Choice C reason:
Removing the stopcocks from IV tubing does not directly address the risk of latex exposure in a surgical setting.
Choice D reason:
Cleansing stoppers with povidone-iodine is a good practice for infection control but does not specifically address the risk of latex exposure for a client with a latex allergy during surgery.
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