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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

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

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential Provider Prescription	Expected or Unexpected?	Explanation
Administer acyclovir.	Unexpected	Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause.
Administer lorazepam.	Expected	Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention.
Initiate 1:1 supervision.	Expected	The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.	Expected	The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration.

Correct Answer is []

Explanation

Condition Most Likely Experiencing:

Delirium

The client's acute confusion, restlessness, disorientation, and inability to perform basic tasks suggest delirium rather than dementia or normal aging. Delirium often has an underlying cause, such as infection or medication side effects, and requires immediate intervention.

Actions to Take:

Monitor for an underlying infection.

Explanation: Infections, particularly urinary tract infections (UTIs) in older adults, are a common cause of delirium. Since the client has been incontinent, an infection could be contributing to the confusion. Identifying and treating the infection can help resolve symptoms.

Use symbols rather than written signs for directions.

Explanation: Since the client is confused and struggling to recognize basic instructions (e.g., confusing the call light with the TV remote), visual cues like symbols can help them navigate their environment and follow instructions more easily.

Parameters to Monitor:

Presence of agnosia.

Explanation: Agnosia (difficulty recognizing objects or their use) can indicate cognitive decline. The client mistaking a washcloth for something that belongs in a dryer suggests possible cognitive impairment, and tracking this symptom will help assess changes in mental status.

Ability to complete familiar tasks.

Explanation: Monitoring whether the client can complete daily activities (e.g., using the call light correctly, self-care) will help determine if their confusion is improving or worsening over time.

Incorrect Choices and Explanations:

Anticipate a prescription for donepezil.

Why Incorrect? Donepezil is used for Alzheimer’s disease, which develops gradually, unlike delirium, which is sudden and reversible if the cause is treated.

Anticipate a prescription for duloxetine.

Why Incorrect? Duloxetine is an antidepressant. While depression can cause confusion, this case strongly suggests acute delirium rather than major depressive disorder.

Determine the date of the client’s last eye examination.

Why Incorrect? Vision problems are not the primary concern in this case. The client's confusion is more likely related to delirium rather than visual impairment.

Night vision.

Why Incorrect? While vision problems can impact safety, the client’s confusion is the main issue here, not their ability to see at night.

Attendance at group therapy.

Why Incorrect? Group therapy is useful for conditions like depression or dementia but does not address the immediate, acute nature of delirium.

Oxygen saturation.

Why Incorrect? The client’s oxygen saturation is already normal (97%), making it an unlikely cause of the delirium. The focus should be on potential infection or other triggers.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Correct Answer is []

Explanation

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