A nurse is caring for a client in the intensive care unit who suddenly becomes confused and agitated. The nurse recognizes these manifestations are likely related to a condition with which of the following characteristics?
Isolated
permanent
Reversible
Unique
The Correct Answer is C
A. Isolated: This term refers to something that is separate or distinct. Confusion and agitation in a client are not typically isolated but can be part of a broader clinical picture.
B. Permanent: These manifestations are not typically permanent and can often be reversed with appropriate interventions.
C. Reversible: Confusion and agitation in a client are often reversible and can be due to various factors such as medications, infections, metabolic disturbances, or other medical conditions. Identifying and addressing the underlying cause can often restore the client to their baseline mental status.
D. Unique: While every individual's presentation may have unique aspects, confusion and agitation are not considered unique manifestations in the context of acute changes in mental status. They are common symptoms that can occur due to a variety of reasons and are not exclusive to any particular condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Comply with compression therapy: Compression therapy is commonly used in the management of peripheral vascular disease (PVD), not valvular heart disease. It involves applying external pressure to the limbs to improve circulation and reduce edema. While this intervention may be relevant for a client with PVD, it is not specific to valvular heart disease.
B. Monitor wounds on lower extremities: Monitoring wounds on lower extremities is important for clients with peripheral vascular disease (PVD) to assess for signs of poor wound healing, infection, or tissue ischemia. However, it is not directly related to valvular heart disease. Therefore, while wound monitoring may be appropriate for this client, it is not specific to valvular heart disease education.
C. Take antiplatelet medications as ordered: Antiplatelet medications, such as aspirin or clopidogrel, are commonly prescribed for clients with peripheral vascular disease (PVD) to reduce the risk of thrombotic events and improve blood flow. However, they are not typically indicated as a primary treatment for valvular heart disease. While some clients with valvular heart disease may have comorbidities that warrant antiplatelet therapy, it is not specific to valvular heart disease education.
D. Valvular heart disease involves dysfunction of one or more heart valves, leading to impaired blood flow within the heart. The nurse should educate the client on monitoring for the gradual onset of symptoms related to valvular heart disease. These symptoms may include dyspnea (shortness of breath), fatigue, palpitations, chest discomfort, and edema. Monitoring for these symptoms allows for early detection of disease progression or exacerbation, prompting timely intervention and management.
Correct Answer is B
Explanation
A. Dopamine: Dopamine is a catecholamine often used to increase blood pressure and cardiac output in hypotensive states. It does not directly reduce intracranial pressure (ICP).
B. Mannitol: Mannitol is an osmotic diuretic commonly used to reduce intracranial pressure in clients with conditions such as subarachnoid hemorrhage, traumatic brain injury, or cerebral edema. It works by drawing fluid from brain tissue into the bloodstream, thereby reducing cerebral edema and ICP.
C. Nicardipine: Nicardipine is a calcium channel blocker used primarily to lower blood pressure in hypertensive emergencies. While it can indirectly impact intracranial pressure by reducing cerebral perfusion pressure, its primary mechanism of action is not targeted at reducing ICP.
D. Phenytoin: Phenytoin is an antiepileptic medication used to prevent and control seizures. While it may be indicated in clients who have experienced a subarachnoid hemorrhage to prevent seizures, it does not directly reduce intracranial pressure.
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