A nurse is caring for a client in the intensive care unit.

Exhibits

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

Answer and Explanation

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

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Correct Answer is C

Explanation

A. Varicella-zoster requires airborne and contact precautions due to the highly contagious nature of chickenpox (varicella) and shingles (zoster).

B. Vancomycin-resistant enterococcus (VRE) typically requires contact precautions to prevent transmission.

C. Pertussis is spread via respiratory droplets, so droplet precautions are necessary to prevent transmission.

D. Rotavirus is transmitted via the fecal-oral route and typically requires contact precautions.

A. Crepitus B. Elevated pulmonary artery pressure C. Hepatosplenomegaly D. Confusion

Correct Answer is B

Explanation

A. Crepitus is not typically associated with right ventricular heart failure; it may indicate subcutaneous emphysema or air leakage into the tissues.

B. Right ventricular heart failure often leads to elevated pulmonary artery pressure due to increased pressure in the pulmonary circulation.

C. Hepatosplenomegaly may occur in congestive heart failure but is not specific to right ventricular heart failure.

D. Confusion may occur in severe cases of heart failure due to decreased cerebral perfusion, but it is not specific to right ventricular heart failure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

Correct Answer is C

Explanation

A nurse is reviewing the history and physical of a client who has right ventricular heart failure.Which of the following is an expected finding?

Correct Answer is B

Explanation

A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?

A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?

A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse prioritize?

A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints?

A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following findings requires immediate intervention by the nurse?

A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?

A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?