A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?
Determine the client's level of consciousness
Administer an anxiolytic medication.
Keep lights on in the client's room.
Encourage visits from family members.
The Correct Answer is A
Choice A Reason:
Determining the client's level of consciousness is correct. Delirium is characterized by a sudden change in mental status, including altered consciousness, confusion, and impaired attention. Assessing the client's level of consciousness helps the nurse understand the severity of the condition and whether the client is experiencing any immediate risks.
Choice B Reason:
Administer an anxiolytic medication is incorrect. Medication administration should not be the first action because the nurse needs to assess the client's condition first to determine if medication is appropriate. Additionally, the underlying cause of the delirium should be identified and treated if possible.
Choice C Reason:
Keep lights on in the client's room is incorrect. While maintaining proper lighting can be important for safety, it is not the first action because it doesn't address the underlying cause or assess the client's level of consciousness.
Choice D Reason:
Encouraging visits from family members is incorrect. Involving family members can provide emotional support, but it's not the first action because the client's condition should be assessed and stabilized before involving others in care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Positioning the knot of the rope at the top of the pulley is incorrect. The knot should be placed at the foot of the bed to ensure proper traction.
Choice B Reason:
Removing the weights for 20 minutes without a healthcare provider's order is not appropriate. If the client experiences severe pain, the nurse should assess the client, evaluate the traction system, and notify the healthcare provider if necessary.
Choice C Reason:
Applying 6.8 kg (15 lb) of weight for use in traction is not the standard practice. The amount of weight used in Buck's traction varies depending on the healthcare provider's orders and the client's specific condition. The nurse should follow the healthcare provider's orders regarding the amount of weight to apply.
Choice D Reason:
Compare bilateral pedal pulses. When caring for a client with Buck's traction, it is essential to regularly assess the circulation to the extremity in traction. Comparing bilateral pedal pulses helps the nurse determine if there are any circulation issues in the affected leg. If the client's circulation is compromised, it can lead to complications such as deep vein thrombosis (DVT) or compartment syndrome.
Correct Answer is B
Explanation
Choice A Reason:
Recording blood glucose levels during a 24-hour creatinine clearance test is not typically necessary for this test. This test primarily measures kidney function, not blood glucose levels.
Choice B Reason:
"You can begin collection of urine after discarding your first morning void." When conducting a 24-hour creatinine clearance test, the client should begin the collection of urine after discarding their first morning void. This helps ensure that the urine collected during the test is a continuous sample that includes both daytime and nighttime urine output. The client should discard the first void of the day but then collect all urine voided for the next 24 hours, including the first void of the following morning.
Choice C Reason:
Eating a protein-rich diet during the collection period can affect the accuracy of the test results, as it may increase creatinine excretion. The client should follow the healthcare provider's instructions regarding dietary restrictions.
Choice D Reason:
Cleansing the perineal area with an antiseptic towel each time before voiding is not typically required for this test. It is more important to ensure that all urine is collected and that the collection container is stored properly to prevent contamination.
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