A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?

Sleep deprivation

Normal signs of aging

Dementia

Delirium

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Sleep deprivation is incorrect. While sleep deprivation can cause confusion and disorientation, it is less likely to cause abrupt onset of altered mental status and hallucinations. Sleep deprivation typically results in gradual cognitive decline and fatigue rather than sudden changes.

Choice B Reason:

Normal signs of aging is incorrect. Normal aging can involve some cognitive decline, but it does not typically cause sudden and severe symptoms like hallucinations and significant disorientation. These symptoms are more indicative of an acute condition.

Choice C Reason:

Dementia is incorrect. Dementia involves a gradual decline in cognitive function over time and does not typically present with sudden onset of symptoms. While dementia can include hallucinations and disorientation, these symptoms usually develop progressively.

Choice D Reason:

Delirium is correct. Delirium is characterized by a sudden onset of confusion, disorientation, and changes in mental status. It is often triggered by acute medical conditions such as infections, including UTIs. Elderly patients are particularly susceptible to delirium, which can include symptoms like hallucinations and severe confusion.

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Correct Answer is C

Explanation

Choice A Reason:

“I will keep spare crutch tips handy.” This statement is correct and indicates good practice. Keeping spare crutch tips handy ensures that the client can replace worn or damaged tips promptly, maintaining the safety and effectiveness of the crutches.

Choice B Reason:

“I will inspect my crutches every day for signs of wear.” This statement is also correct. Regular inspection of crutches for signs of wear and tear helps prevent accidents and ensures that the crutches remain in good working condition.

Choice C Reason:

“I will bear the weight of my body on my axillas.” This statement is incorrect and indicates that the client needs additional education. Bearing weight on the axillas (armpits) can cause nerve damage and discomfort. The correct technique is to support the body’s weight with the hands and arms, not the axillas.

Choice D Reason:

“I will support most of the weight of my body with my arms.” This statement is correct. Supporting the body’s weight with the arms and hands is the proper technique for using crutches, as it prevents nerve damage and ensures better control and stability.

A. Asthma B. Hypertension C. Glaucoma D. Depression

Correct Answer is C

Explanation

Choice A reason: Asthma

Diphenhydramine is an antihistamine that can cause drying of the airways and thickening of bronchial secretions, which might exacerbate asthma symptoms. However, it is not strictly contraindicated in asthma patients. Instead, caution is advised, and it should be used under medical supervision if necessary.

Choice B reason: Hypertension

While diphenhydramine can cause mild increases in blood pressure due to its anticholinergic effects, it is not contraindicated in patients with hypertension. Patients with hypertension should use it cautiously and under medical advice, but it is not an absolute contraindication.

Choice C reason: Glaucoma

Diphenhydramine is contraindicated in patients with glaucoma, particularly closed-angle glaucoma. This is because diphenhydramine has anticholinergic properties that can increase intraocular pressure, potentially worsening the condition. Patients with glaucoma should avoid using diphenhydramine to prevent complications related to increased eye pressure.

Choice D reason: Depression

Diphenhydramine is not contraindicated in patients with depression. However, it can cause drowsiness and sedation, which might affect mood and energy levels. Patients with depression should use it cautiously and under medical supervision, but it is not an absolute contraindication.

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A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which statement would the nurse identify as an indication that the client needs additional education?

Correct Answer is C

Explanation

A client asks the nurse about a prescription for the antihistamine, diphenhydramine (Benadryl). The nurse should teach the client that this medication is contraindicated in clients who have a history of which condition?

Correct Answer is C

Explanation

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