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 C
Explanation
A. There is no known significant interaction between garlic supplements and antidepressants.
B. There is no evidence to suggest that garlic supplements are contraindicated for individuals with a history of seizure disorders. Garlic is not known to exacerbate seizure activity or interact with anticonvulsant medications.
C. Garlic has antiplatelet properties, which can increase the risk of bleeding, especially when combined with other blood-thinning agents like aspirin. Clients who take aspirin daily are at an increased risk of bleeding complications if they also take garlic supplements. This makes it a contraindication in such cases.
D. There are no known contraindications specifically related to rheumatoid arthritis and garlic supplements.
Correct Answer is C
Explanation
A. Providing guidance on incentive spirometry requires specialized knowledge and skill that should be provided by a licensed healthcare provider, such as a nurse.
B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires ongoing assessment and monitoring by a licensed healthcare provider, such as a nurse, due to the potential for cardiac complications.
C. Assisting a client who had a stroke 2 days ago and needs help toileting is a task that can be safely delegated to an assistive personnel, as long as the client's condition is stable and the assistive personnel has been trained in providing basic care.
D. Providing a drink to a client who has awoken following a bronchoscopy may require assessment and monitoring for potential complications, such as aspiration or respiratory distress, which should be provided by a licensed healthcare provider, such as a nurse.
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