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
The cervical cap should be left in place for a minimum of 6 hours after intercourse but should not exceed a total of 48 hours of continuous use. Leaving it in place for longer periods may increase the risk of toxic shock syndrome (TSS) and other potential complications. Using a cervical cap in combination with a spermicide is the recommended practice for maximizing its effectiveness. Spermicide helps immobilize or kill sperm, providing an additional barrier against pregnancy when used with the cervical cap.
Using the cervical cap during the menstrual cycle is not a recommended practice for contraception. The cervical cap is primarily used during sexual activity as a barrier method of contraception and is not specifically designed for use during menstruation.
While it is important for the provider to initially fit and size the cervical cap for the client, routine checks every 6 months are not necessary. However, it is still important for the client to regularly inspect the cap for any signs of damage or deterioration and replace it as needed.
Correct Answer is C
Explanation
Choice A Reason:
Flossing between a 12-month-old's teeth is not typically necessary, as most children do not have enough teeth for flossing at this age. Flossing becomes more important as a child's dentition develops.
Choice B Reason:
Positioning the toothbrush bristles at a 90-degree angle is not appropriate for a 12-month-old child. Parents should use a gentle, circular brushing motion, as this is more effective and less likely to cause discomfort or injury to the child's gums and teeth.
Choice C Reason:
Cleaning the teeth with a small, soft-bristled toothbrush is correct. When teaching a parent about preventing dental caries in a 12-month-old toddler, it's important to provide appropriate guidance for oral care. Using a small, soft-bristled toothbrush is recommended for young children because it is gentle on their gums and teeth. Here's why the other options are not suitable:
Choice D Reason:
Using a 5-inch strip of toothpaste on the toothbrush is excessive for a 12-month-old. The American Academy of Pediatrics recommends using only a small smear or grain-sized amount of fluoride toothpaste for children under 3 years old to minimize the risk of swallowing too much fluoride.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today