A nurse is caring for a client who is receiving mechanical ventilation following a stroke.

Which of the following actions should the nurse take?

Cluster nursing care activities.

Hyperoxygenate the client before suctioning.

Keep the room well lit to orient the client.

Maintain the client's PaCO2 at 50 mm Hg.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.

Choice B rationale:

Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.

Choice C rationale:

Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.

Choice D rationale:

Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.

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Correct Answer is A

Explanation

Choice A rationale:

Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.

Choice B rationale:

Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.

Choice C rationale:

Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.

Choice D rationale:

Using the client's name is respectful and helpful, but it is not the priority action in this scenario.

A. Agitation B. Slow, flat speech C. Visual hallucinations D. Confusion E. Rapid mood swings

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

Explanation

Choice A rationale:

Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.

Choice B rationale:

Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.

Choice C rationale:

Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.

Choice D rationale:

Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.

Choice E rationale:

Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.

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A nurse is caring for a client who is receiving mechanical ventilation following a stroke. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newly admitted client who has schizophrenia. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)

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

Explanation

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A nurse is caring for a client who is receiving mechanical ventilation following a stroke.

Which of the following actions should the nurse take?