A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?

Hallucinations

Agnosia

Bradycardia

Aphasia

Answer and Explanation

The Correct Answer is A

A. Hallucinations - Delirium can cause perceptual disturbances such as hallucinations, where the client perceives things that are not actually present.

B. Agnosia - Agnosia refers to the inability to recognize familiar objects, which is not typically associated with delirium.

C. Bradycardia - Delirium is not typically associated with bradycardia; it may actually be associated with tachycardia due to the physiological stress response.

D. Aphasia - Aphasia refers to the loss of ability to understand or express speech, which is not typically associated with delirium.

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Correct Answer is B

Explanation

A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.

B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.

C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.

D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.

A. Use the injection port farthest from the IV catheter insertion site. B. Occlude the IV tubing above the injection port. C. Check for blood return after medication administration. D. Flush the IV tubing with a heparinized solution.

Correct Answer is B

Explanation

A. Using the injection port farthest from the IV catheter insertion site is not necessary for administering an IV bolus of medication and may not be practical depending on the setup of the IV tubing.

B. Occluding the IV tubing above the injection port prevents the bolus medication from flowing into the continuous IV infusion, ensuring that the medication is delivered directly to the patient.

C. Checking for blood return after medication administration is not relevant in this context, as albumin 5% is administered intravenously and does not require blood return.

D. Flushing the IV tubing with a heparinized solution is not necessary for administering an IV bolus of medication and may not be appropriate for all medications.

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A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?

Nursing Test Bank

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