A nurse is caring for a client who is experiencing delirium. Which of the following findings should the nurse expect?

Catatonia

Echopraxia

Agraphia

Illusions

Answer and Explanation

The Correct Answer is D

A. Catatonia. Catatonia involves significant motor disturbances such as rigidity, mutism, or excessive movement, commonly seen in schizophrenia or severe mood disorders. Delirium is characterized by acute confusion, fluctuating attention, and perceptual disturbances rather than motor abnormalities.
B. Echopraxia. Echopraxia is the involuntary repetition of another person’s movements, often linked to schizophrenia and autism spectrum disorders. Delirium primarily presents with disorientation, altered consciousness, and hallucinations rather than repetitive motor behaviors.
C. Agraphia. Agraphia is the loss of the ability to write due to neurological conditions like stroke or dementia. Delirium is an acute and reversible cognitive disturbance that affects attention and perception but does not typically result in isolated language deficits.
D. Illusions. Illusions involve the misinterpretation of real stimuli, such as mistaking a cord for a snake, and are common in delirium. This occurs due to the client's fluctuating mental status, impaired sensory perception, and difficulty distinguishing reality from distorted perceptions.

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Correct Answer is C

Explanation

A. Asking the client to point their toes before applying the stockings is an appropriate action. This maneuver helps to flex the foot, making it easier to apply the stockings and ensuring they fit properly without causing discomfort.
B. Turning the stockings inside out before applying them is an acceptable practice as it can make them easier to put on and ensure they fit well on the client’s leg. This action does not require intervention.
C. Ensuring that creases in the stockings are on the front of the client's legs requires intervention. The stockings should be applied smoothly and without creases to prevent pressure areas, which could lead to skin breakdown or complications. Creases should be avoided on any part of the stockings that may cause discomfort or impede circulation.
D. Applying the stockings before the client gets out of bed is appropriate. Antiembolic stockings are often applied while the client is in bed to prevent complications associated with immobility, such as deep vein thrombosis (DVT). This action supports patient safety and comfort.

A. Obtain a large-bore IV catheter. B. Explain to the client that transfusion reactions are not serious. C. Ensure two nurses confirm the information on the blood label. D. Ensure the transfusion tubing is flushed with dextrose 5% in water. E. Witness the client signing consent for transfusion.

Correct Answer is ["A","C","E"]

Explanation

A. Obtain a large-bore IV catheter. A large-bore IV catheter (18-gauge or larger) is necessary for blood transfusion to allow for rapid administration and reduce the risk of hemolysis. The provider has already prescribed this intervention.
B. Explain to the client that transfusion reactions are not serious. This statement is inaccurate and misleading. While many transfusion reactions are mild, some can be life-threatening, such as hemolytic reactions or anaphylaxis. The nurse should educate the client about signs and symptoms of a transfusion reaction and instruct them to report any discomfort or unusual sensations immediately.
C. Ensure two nurses confirm the information on the blood label. Before administering blood, two nurses must verify the blood product against the client's identification band, medical record, and blood bank documentation to prevent transfusion errors.
D. Ensure the transfusion tubing is flushed with dextrose 5% in water. Blood products should only be administered with normal saline (0.9% sodium chloride) because dextrose-containing solutions can cause red blood cell hemolysis. The nurse should ensure the IV tubing is primed with normal saline before starting the transfusion.
E. Witness the client signing consent for transfusion. Informed consent is required before administering a blood transfusion. While obtaining consent is the provider’s responsibility, the nurse can witness the signing and ensure that the client understands the procedure.

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Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A nurse is caring for a client who is experiencing delirium. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is C

Explanation

The nurse is reviewing the client's medical record. Exhibits The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

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