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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason:

Limiting fluid intake to 750 mL per day is not recommended, as adequate hydration is essential for overall health. The client should maintain good hydration unless specifically advised otherwise by their healthcare provider.

Choice B Reason:

Cleansing the neck by rubbing with a washcloth may be too harsh for the irradiated skin. The skin in the radiation field can become sensitive and may require gentle cleansing with mild soap and patting dry, rather than rubbing.

Choice C Reason:

Eating three large meals each day may not be suitable for all clients undergoing radiation therapy, especially if they are experiencing side effects such as difficulty swallowing or changes in taste. Dietary recommendations should be individualized based on the client's specific needs and symptoms. Smaller, more frequent meals may be more manageable for some clients.

Choice D Reason:

Avoiding exposing the neck to the cold is correct. When providing instructions to a client undergoing radiation therapy to the neck, it's important to emphasize the need to protect the treated area from extreme temperature changes. Exposure to cold temperatures can cause vasoconstriction and potentially lead to tissue damage in the irradiated area. Therefore, advising the client to avoid exposing the neck to cold is a vital precaution.

A. Administer an anti-anxiety medication. B. Explore behaviors that have helped to reduce the client's anxiety in the past. C. Minimize environmental stimuli in the client's surroundings. D. Explain to the client that anxiety causes physical manifestations

Correct Answer is C

Explanation

The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.

While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.

Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.

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A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse Include in the teaching?

Correct Answer is D

Explanation

A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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