A nurse is assisting in the care of a client in the intensive care unit (ICU)

Exhibits
The nurse should identify which of the following client's conditions can indicate the development of delirium.

past medical history

illusions

change in orientation

hallucinations

Answer and Explanation

Correct Answer : C,D

Rationale:

• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.

• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.

• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.

• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.

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Correct Answer is A

Explanation

Rationale:

A. Decreased heart rate: Propranolol is a non-selective beta-blocker that reduces heart rate by blocking beta-1 receptors in the heart. Bradycardia is a common and expected adverse effect, and clients should be taught to monitor their pulse regularly and report significant drops.

B. Sudden weight loss: Sudden weight loss is not a typical adverse effect of propranolol. If it occurs, it may indicate an underlying condition or adverse reaction unrelated to the pharmacologic action of beta-blockers and should be evaluated separately.

C. Increased urinary output: Propranolol does not act on the kidneys to promote diuresis. While beta-blockers may be used in combination with diuretics, increased urine output is not a direct effect of this medication and is not expected.

D. White patches on the tongue: White patches on the tongue suggest oral candidiasis, which is more commonly associated with inhaled corticosteroids, not beta-blockers like propranolol. This symptom is unrelated to the medication’s mechanism of action.

A. Tilt the client's head forward during meals. B. Encourage socialization during meal times. C. Elevate the head of the client's bed to 30", D. Provide three large meals per day.

Correct Answer is A

Explanation

Rationale:

A. Tilt the client's head forward during meals: Tilting the head forward, also known as the chin-tuck technique, helps close the airway and reduce the risk of aspiration in clients with dysphagia. This position facilitates safer swallowing by improving bolus control and airway protection.

B. Encourage socialization during meal times: While social interaction is generally beneficial, clients with dysphagia require focused attention during meals to prevent choking or aspiration. Distractions can compromise concentration on swallowing techniques and safety precautions.

C. Elevate the head of the client's bed to 30": Although elevating the head of the bed helps reduce aspiration risk, a 30" elevation is not optimal for swallowing. A 45–90 degree upright position is typically recommended during meals to support safer swallowing mechanics.

D. Provide three large meals per day: Clients with dysphagia benefit more from small, frequent meals to reduce fatigue and lower the risk of aspiration. Large meals can overwhelm their ability to chew and swallow safely, increasing the risk of complications.

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A nurse is assisting in the care of a client in the intensive care unit (ICU) Exhibits The nurse should identify which of the following client's conditions can indicate the development of delirium.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a new prescription for propranolol. The nurse should include which of the following as a potential adverse effect of this medication?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is assisting in the care of a client in the intensive care unit (ICU)

Exhibits
The nurse should identify which of the following client's conditions can indicate the development of delirium.