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. Discarding opened cans of formula after 24 hours helps prevent bacterial contamination and growth, which can contribute to diarrhea in clients receiving enteral feedings.
B. Extension tubing should be replaced according to institutional policy and manufacturer recommendations, typically every 24 to 48 hours, but it is not directly related to diarrhea management.
C. Irrigating the tubing with warm water is not a standard practice for managing diarrhea in clients receiving enteral feedings and may disrupt the client's fluid and electrolyte balance.
D. Increasing the infusion rate of enteral feedings is not indicated for managing diarrhea and may exacerbate the problem by overwhelming the client's gastrointestinal tract. The rate of enteral feeding should be adjusted based on the client's nutritional needs and tolerance, as determined by the healthcare provider.
Correct Answer is A
Explanation
A.
A. Brainstorming sessions are designed to generate new ideas and solutions by encouraging free thinking and creativity among participants. This approach can be effective in generating
innovative strategies to address public health concerns.
B. While a community-wide program may be part of addressing the issue, it does not inherently involve generating new ideas but rather implementing existing strategies on a larger scale.
C. Role-playing with nurses may be a training method to improve communication or intervention skills, but it is not specifically aimed at generating new ideas to address public health concerns.
D. Personal discussions with clients are important for providing individualized care and support but may not directly contribute to generating new ideas to address community-wide public health concerns.
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