A nurse is caring for a client in the intensive care unit.
The nurse is reviewing the admission assessment, nurses' notes, vital signs, and laboratory results. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies that the client's and can indicate the development of delirium.
illusions
past medical history
hallucinations
changes in orientation
Correct Answer : C,D
A. illusions aren’t common in delirium
B. the client’s past medical history isn’t indicative of delirium.
C. Delirium can manifest as disorientation, confusion, agitation, restlessness, illusions, or hallucinations. It can also impair memory, judgment, and language.
D. Delirium can manifest as disorientation, confusion, agitation, restlessness, illusions, or hallucinations. It can also impair memory, judgment, and language.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sputum culture is used to diagnose active tuberculosis but is not typically used for routine screening of asymptomatic individuals.
B. Chest x-ray can detect active tuberculosis or its complications but is not typically used for routine screening of asymptomatic individuals.
C. QuantiFERON-TB Gold blood analysis is a blood test that detects the presence of tuberculosis infection but is not typically used for routine screening of asymptomatic individuals.
D. The Mantoux test, also known as the tuberculin skin test (TST), is commonly used for routine screening of tuberculosis infection in asymptomatic individuals, including new employees in healthcare settings.
Correct Answer is A
Explanation
A.
A. A BMI of 20 falls within the healthy weight range for adults, indicating that the client's weight is appropriate for his height.
B. A BMI of 20 is not indicative of malnutrition. Malnutrition is typically associated with lower BMIs.
C. A BMI of 20 is not within the overweight range, as overweight is typically defined as a BMI between 25 and 29.9.
D. A BMI of 20 is not within the obesity range, as obesity is typically defined as a BMI of 30 or higher.
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