A nurse is caring for an older adult client.
Complete the following sentence by using the list of options.
Upon assessment, the nurse should recognize that the client is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Upon assessment, the nurse should recognize that the client is at risk for developing acute confusion or delirium as evidenced by the client's disorientation to time and place, inability to focus, agitation, and anxiety upon reorientation. These symptoms suggest a disruption in cerebral metabolism, which can be caused by a variety of factors such as infection, fluid or electrolyte imbalance, or medication side effects. It is crucial to identify the underlying cause to provide appropriate care and prevent further complications. The nurse's role includes monitoring the patient's mental status, ensuring safety, and implementing therapeutic interventions to create a calming environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Encouraging physical activity during the day has been shown to improve mood and reduce symptoms of depression by increasing endorphin levels and promoting a sense of well-being.
B. Identifying and scheduling alternative group activities for the client may be helpful in reducing social isolation and improving mood but should not replace physical activity.
C. Discouraging the client from expressing feelings of anger is not appropriate, as it may suppress emotions and hinder therapeutic communication. Instead, the nurse should encourage the client to express and explore their emotions in a healthy manner.
D. Keeping a bright light on in the client's room at night may disrupt sleep patterns and exacerbate symptoms of depression, as individuals with depression often have disturbances in their sleep-wake cycle.
Correct Answer is A
Explanation
A. This response acknowledges the client's feelings and validates their experience without confirming or denying the delusion.
B. This response challenges the client's belief and may cause distress or exacerbate paranoia.
C. While factually correct, this response may not address the client's underlying concerns or feelings.
D. This response may invalidate the client's experience and may not effectively address the delusional belief.
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