A nurse is assisting in the care of a client in the intensive care unit (ICU)
past medical history
illusions
change in orientation
hallucinations
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Headaches with aura: Headaches accompanied by aura are a strong contraindication to oral contraceptive use due to the significantly increased risk of thromboembolic events, particularly ischemic stroke. Estrogen-containing contraceptives can further exacerbate this vascular risk, making alternative forms of birth control necessary.
B. Gastroesophageal reflux disease: GERD is a gastrointestinal condition that does not affect the safety or efficacy of oral contraceptives. Although hormonal fluctuations can sometimes influence gastric symptoms, GERD is not a contraindication to contraceptive use.
C. History of mononucleosis 1 year ago: A past infection with mononucleosis does not impact liver function long-term in most cases and does not interfere with hormonal contraceptive use. It does not pose any increased risk related to estrogen or progesterone components.
D. Irregular menstrual cycles: While irregular cycles are a common reason for initiating oral contraceptives, they are not a contraindication. In fact, hormonal contraceptives are often used therapeutically to regulate menstrual patterns and reduce cycle variability.
Correct Answer is C
Explanation
Rationale:
A. Removing an NG tube: Removing a nasogastric tube is a task that can be safely delegated to a licensed practical nurse (LPN) under appropriate supervision, as it is considered a stable, routine procedure that does not require complex assessment.
B. Administering a subcutaneous insulin injection: LPNs are trained and authorized to administer subcutaneous injections, including insulin, as long as the client's condition is stable and the dose is clearly prescribed.
C. Providing discharge teaching about home IV medication therapy: Discharge education involving IV therapy requires comprehensive teaching, clinical judgment, and evaluation of understanding, which falls within the scope of practice of a registered nurse (RN).
D. Collecting a sputum culture: Collecting a sputum specimen is a basic nursing task that can be performed by an LPN or even by trained assistive personnel, depending on facility policy. It does not require the expertise of an RN.
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