A nurse is assisting in the care of a client in the emergency department (ED). Nurses' Notes 0205: Client brought to the ED by police after being found wandering on the street.
Client able to provide identity to police but not able to identify place or time.
Family notified.
Client confused and agitated.
Appearance is disheveled.
Mucous membranes dry.
Lungs clear and equal, heart rhythm regular.
During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
Vital Signs 0200: Temperature 38.6°C (101.5°F), Heart rate 104/min, Respiratory rate 18/min, Blood pressure 158/96 mm Hg, Oxygen saturation 98% on room air.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
Client confused and agitated.
Appearance is disheveled.
Mucous membranes dry
During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
Temperature 38.6°C (101.5°F)
Blood pressure 158/96 mm Hg
Heart rate 104/min
Respiratory rate 18/min
Oxygen saturation 98% on room air.
The Correct Answer is ["A","B","C","D","E","F"]
The findings that require immediate follow-up are:
- Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
- Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
- Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly.
- Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
- Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
- Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A consistent state of depression is not indicative of delirium, but rather a mood disorder.
Choice B rationale:
Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
Choice C rationale:
Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
Choice D rationale:
Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
Correct Answer is B
Explanation
Choice A rationale:
Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.
Choice B rationale:
Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.
Choice C rationale:
The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.
Choice D rationale:
Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.