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 B
Explanation
A. A flexible activity schedule may increase overstimulation; structured activities with set limits are more appropriate for clients in acute mania.
B. Clients experiencing acute mania often have increased energy expenditure and may neglect meals; providing high-calorie nutritional supplements helps prevent weight loss and maintains adequate nutrition.
C. Eating alone may increase the risk of inadequate intake due to distraction or hyperactivity; supervised or structured meal times are safer.
D. Allowing unrestricted choice of clothing may lead to inappropriate or disorganized attire; guidance is needed to maintain safety and appropriate appearance.
Correct Answer is C
Explanation
A. Varicella-zoster (chickenpox) requires airborne precautions due to its transmission via respiratory droplets or aerosols.
B. Vancomycin-resistant enterococcus (VRE) is typically transmitted through direct contact with contaminated surfaces or equipment and does not require droplet precautions.
C. Pertussis (whooping cough) is transmitted via respiratory droplets and requires droplet precautions to prevent transmission to others.
D. Rotavirus is primarily transmitted through the fecal-oral route and requires contact precautions, not droplet precautions.
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