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","B","D"]

Explanation

Rationale:

• "Use sunglasses if your eyes are sensitive to light." Exophthalmos from Graves' disease can persist even after thyroidectomy. Sunglasses help reduce photophobia and protect protruding eyes from dryness and injury.

• "Continue eating foods with protein." Protein is essential for wound healing and energy. Postoperative hypermetabolic states can also increase protein needs, so adequate intake supports recovery.

• "You need to support your neck when coughing or moving." Neck support prevents strain on the surgical site and reduces the risk of wound dehiscence or hematoma formation during activities that increase intrathoracic pressure.

• "Remain on bedrest for 3 to 5 days following discharge." Prolonged bedrest is not recommended post-thyroidectomy. Early ambulation reduces risk of complications such as pneumonia and deep vein thrombosis and supports normal recovery.

• "You will no longer need to take any medications for your thyroid now that you have had surgery." Total or subtotal thyroidectomy often results in hypothyroidism, requiring lifelong thyroid hormone replacement (e.g., levothyroxine). Medication needs depend on the amount of thyroid tissue removed.

A. "I feel that soon everything will be ok." B. "I just cannot take this anymore. C. "My family would be better off if i was dead." D. "I do not want to be here anymore."

Correct Answer is A

Explanation

Rationale:

A. "I feel that soon everything will be ok.": This is a covert statement because it sounds hopeful but may actually reflect a decision to end one’s life. Sudden calmness or vague optimism in someone with a history of major depressive disorder can indicate suicidal planning and should prompt immediate follow-up.

B. "I just cannot take this anymore.": This is an overt expression of emotional distress and hopelessness. While serious, it clearly communicates the client's feelings and is more direct than covert.

C. "My family would be better off if I was dead.": This is an overt suicidal statement suggesting that the client believes their death would benefit others. It requires immediate attention and suicide risk assessment.

D. "I do not want to be here anymore.": This is another overt expression that directly indicates a desire to no longer live or be present. It reflects suicidal ideation and needs urgent intervention but is not considered covert.

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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

The nurse has reviewed the Vital Signs at 1000. Exhibits Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

Correct Answer is ["A","B","D"]

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.