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 []

Explanation

Rationale:

Dependent personality disorder: Characterized by excessive need to be taken care of and fear of separation. This does not fit the client’s symptoms of hopelessness, poor hygiene, flat affect, and suicidal thoughts, which are more consistent with major depression.
Schizophrenia: Involves hallucinations, delusions, and disorganized behavior, none of which are reported in this client. The absence of psychosis and the presence of mood-based symptoms suggest a depressive disorder rather than a psychotic disorder.
Major depressive disorder: Fits with the client's expression of hopelessness, withdrawal, poor hygiene, job loss, and suicidal ideation. These are classic symptoms of major depression and require careful monitoring and support.
Dementia: Typically includes memory impairment, disorientation, and decline in cognitive function. The client is coherent, oriented, and presenting with mood rather than cognitive issues, ruling out dementia.
Speak with the client using simple words: While clear communication is always beneficial, there is no indication the client has cognitive impairment requiring simplified language. The priority is emotional support and safety, not communication complexity.
Remain in the room with the client: Ensures the client feels supported and safe, especially in the context of suicidal ideation. Continuous presence also allows for immediate intervention if the client's mental state worsens.
Encourage client to eat slowly: Not relevant to the client’s presentation. There are no issues with appetite, swallowing, or physical illness necessitating this intervention. It does not address the mental health concerns at hand.
Assist the client to identify stressors: Helps promote insight and develop coping mechanisms. Identifying stressors is essential in managing depressive symptoms and planning appropriate therapeutic strategies.
Determine client’s level of disorientation: The client is not exhibiting signs of confusion or disorientation. This action would be more appropriate for cognitive disorders such as dementia or delirium.
Panic attacks: The client reports anxiety but has not described acute panic symptoms like hyperventilation or chest tightness. Monitoring panic attacks is not a priority in this depressive context.
Hallucinations: There is no evidence of perceptual disturbances. The client is not demonstrating psychosis, so monitoring for hallucinations is not indicated.
Wandering at night: More relevant for clients with dementia or delirium. This client is coherent and not at risk of nocturnal wandering.
Suicidal ideation: A key concern due to the client expressing that life is not worth living. This must be monitored continuously for client safety and to guide suicide prevention strategies.
Sleep patterns: Depression commonly affects sleep, leading to insomnia or hypersomnia. Monitoring sleep helps gauge treatment response and overall progress in managing depressive symptoms.

A. "Use sunglasses if your eyes are sensitive to light." B. "Continue eating foods with protein." C. "Remain on bedrest for 3 to 5 days following discharge." D. "You need to support your neck when coughing or moving." E. "You will no longer need to take any medications for your thyroid now that you have had surgery."

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.

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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

Correct Answer is []

Explanation

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

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.