A nurse is caring for a client who experienced a fall.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
The Correct Answer is []
Condition Most Likely Experiencing:
Delirium
- The client's acute confusion, restlessness, disorientation, and inability to perform basic tasks suggest delirium rather than dementia or normal aging. Delirium often has an underlying cause, such as infection or medication side effects, and requires immediate intervention.
Actions to Take:
Monitor for an underlying infection.
- Explanation: Infections, particularly urinary tract infections (UTIs) in older adults, are a common cause of delirium. Since the client has been incontinent, an infection could be contributing to the confusion. Identifying and treating the infection can help resolve symptoms.
Use symbols rather than written signs for directions.
- Explanation: Since the client is confused and struggling to recognize basic instructions (e.g., confusing the call light with the TV remote), visual cues like symbols can help them navigate their environment and follow instructions more easily.
Parameters to Monitor:
Presence of agnosia.
- Explanation: Agnosia (difficulty recognizing objects or their use) can indicate cognitive decline. The client mistaking a washcloth for something that belongs in a dryer suggests possible cognitive impairment, and tracking this symptom will help assess changes in mental status.
Ability to complete familiar tasks.
- Explanation: Monitoring whether the client can complete daily activities (e.g., using the call light correctly, self-care) will help determine if their confusion is improving or worsening over time.
Incorrect Choices and Explanations:
Anticipate a prescription for donepezil.
- Why Incorrect? Donepezil is used for Alzheimer’s disease, which develops gradually, unlike delirium, which is sudden and reversible if the cause is treated.
Anticipate a prescription for duloxetine.
- Why Incorrect? Duloxetine is an antidepressant. While depression can cause confusion, this case strongly suggests acute delirium rather than major depressive disorder.
Determine the date of the client’s last eye examination.
- Why Incorrect? Vision problems are not the primary concern in this case. The client's confusion is more likely related to delirium rather than visual impairment.
Night vision.
- Why Incorrect? While vision problems can impact safety, the client’s confusion is the main issue here, not their ability to see at night.
Attendance at group therapy.
- Why Incorrect? Group therapy is useful for conditions like depression or dementia but does not address the immediate, acute nature of delirium.
Oxygen saturation.
- Why Incorrect? The client’s oxygen saturation is already normal (97%), making it an unlikely cause of the delirium. The focus should be on potential infection or other triggers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A consistent state of depression is not indicative of delirium, but rather a mood disorder.
Choice B rationale:
Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
Choice C rationale:
Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
Choice D rationale:
Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
Correct Answer is ["The correct answers are choices: Approach client slowly"," \r\n Maintain a low stimulation environment"," \r\n and Reorient client to person"," \r\n place"," \r\n and time frequently. Approach client slowly rationale: This is a therapeutic intervention for clients who are confused and agitated. It can help to reduce anxiety and promote trust. Alternate nursing staff daily rationale: This is not recommended as it can lead to confusion and anxiety in the client. Consistency in care providers can help to promote trust and understanding. Maintain a low stimulation environment rationale: This can help to reduce agitation and confusion in the client. A calm and quiet environment can promote relaxation and understanding. Reorient client to person"," \r\n place"," \r\n and time frequently rationale: This is a therapeutic intervention for clients who are confused. It can help to promote reality orientation and reduce confusion. Provide the client with limited information about the diagnosis rationale: This is not recommended as it can lead to confusion and anxiety in the client. Clients have the right to be fully informed about their diagnosis and treatment."]
No explanation
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