A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

Flexes the upper and extends the lower extremities in response to the painful stimulus

Pushes the painful stimulus away

Shows no reaction to the painful stimulus

Extends her body toward the painful stimulus

Answer and Explanation

The Correct Answer is B

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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. Review renal function labs B. Prep the client for surgery C. Hold all fluids and food for 24 hours D. Assess the gag reflex

Correct Answer is A

No explanation

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A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

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

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Correct Answer is A

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