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 A
Explanation
A.
A. Hospice care improves quality of life through palliative care - This is a central aspect of hospice care, focusing on pain and symptom management to enhance the patient's comfort and quality of life.
B. Hospice care provides 24-hr, in-home care - While hospice care may provide support, it typically does not offer around-the-clock care in the home.
C. Hospice care is intended to postpone death - Hospice care aims to provide comfort and support in the final stages of life, not to postpone death.
D. Hospice care encourages the family to coordinate health care services - While family
involvement is important, hospice care typically involves a coordinated interdisciplinary team rather than relying solely on family for coordination.
Correct Answer is D
Explanation
A. Restricting dietary calcium intake is not typically recommended for preventing nephrolithiasis; in fact, adequate calcium intake may decrease the risk of kidney stone formation.
B. Limiting fluid intake is not recommended for individuals with nephrolithiasis; adequate fluid intake helps prevent kidney stone formation.
C. Complex carbohydrates do not significantly impact the risk of nephrolithiasis; dietary changes should focus on other factors such as oxalate intake.
D. Foods high in oxalates, such as spinach, beets, nuts, and chocolate, can contribute to the formation of kidney stones in susceptible individuals, so it's important to avoid them.
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