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 B

Explanation

Choice A Reason:

Securing the oxygen tubing to the bed sheet near the client’s head is not recommended because it can lead to accidental dislodgement of the tubing, which can interrupt the oxygen supply. Additionally, this practice does not address the potential for nasal dryness and irritation that can occur with oxygen therapy. Properly securing the tubing should involve ensuring it is comfortably positioned and not at risk of being pulled or dislodged.

Choice B Reason:

Attaching a humidifier bottle to the base of the flow meter is the correct action because it helps to add moisture to the oxygen being delivered to the client. Oxygen therapy, especially at higher flow rates like 5 L/min, can dry out the nasal passages and mucous membranes, leading to discomfort and potential complications. The humidifier bottle ensures that the oxygen is humidified, which helps to prevent dryness and irritation, making the therapy more comfortable and effective for the client.

Choice C Reason:

Applying petroleum jelly to the nares is not recommended because petroleum-based products can be flammable and pose a risk when used in conjunction with oxygen therapy. Additionally, petroleum jelly can trap bacteria and potentially lead to infections. Instead, water-based lubricants or saline nasal sprays are safer alternatives for soothing dry nasal passages.

Choice D Reason:

Removing the nasal cannula while the client eats is not advisable because it interrupts the continuous delivery of oxygen, which is essential for clients with pneumonia who may already have compromised respiratory function. Instead, the nurse should ensure that the nasal cannula is securely in place and that the client is receiving the prescribed oxygen therapy at all times, including during meals.

A. Place suction equipment at the bedside. B. Administer a prophylactic expectorant. C. Encourage the use of an incentive spirometer. D. Perform range of motion exercises.

Correct Answer is C

Explanation

Choice A Reason:

Place suction equipment at the bedside is incorrect. While having suction equipment available is important for emergency situations, it does not directly prevent postoperative pulmonary complications. Suction equipment is used to clear the airway if the client has difficulty breathing or if there is an obstruction.

Choice B Reason:

Administer a prophylactic expectorant is incorrect. Prophylactic expectorants can help in managing secretions, but they are not the primary intervention for preventing postoperative pulmonary complications. The main goal is to promote lung expansion and prevent atelectasis.

Choice C Reason:

Encourage the use of an incentive spirometer is correct. Using an incentive spirometer encourages deep breathing and lung expansion, which helps prevent atelectasis and other postoperative pulmonary complications. It is a key intervention in postoperative care to maintain optimal lung function.

Choice D Reason:

Perform range of motion exercises is incorrect. While range of motion exercises are important for preventing musculoskeletal complications and promoting circulation, they do not directly prevent pulmonary complications. The focus for pulmonary health is on lung expansion and clearing secretions.

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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 caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which action should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a postoperative client. Which intervention should the nurse identify as important to prevent postoperative pulmonary complications?

Correct Answer is C

Explanation

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse positions the client in the orthopneic position. What is the primary reason for the use of this position for this client?

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A nurse is confirming with the client the informed consent signed earlier that day. The client then states, “I have changed my mind and do not want to have the procedure done.” What action should the nurse take?

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?

A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

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