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 C
Explanation
Choice A Reason:
8 lb is not an appropriate weight gain for this client because it falls below the recommended range.
Choice B Reason:
32 lb is excessive weight gain for a client with a prepregnancy BMI of 30.5. Excessive weight gain during pregnancy can increase the risk of various complications, including gestational diabetes, hypertension, and larger-than-average birth weight.
Choice C Reason:
16 lb is within the recommended range for weight gain during pregnancy for a client with a prepregnancy BMI of 30.5. This falls in the range of approximately 11 to 20 pounds (5 to 9 kilograms) of weight gain.
Choice D Reason:
24 lb is above the upper limit of the recommended weight gain range for a client with a prepregnancy BMI of 30.5. It exceeds the upper limit of approximately 20 pounds (9 kilograms) of weight gain.
Correct Answer is A
Explanation
Choice A Reason:
A client who has a spinal cord injury is correct. An interprofessional conference is often recommended for clients with complex and multifaceted health issues that require collaboration among various healthcare disciplines. A client with a spinal cord injury typically has complex care needs that involve multiple healthcare professionals, such as physical therapists, occupational therapists, social workers, nurses, and possibly surgeons or neurologists. The coordination of care for a client with a spinal cord injury often requires input and collaboration from various healthcare team members, making an interprofessional conference valuable.
Choice B Reason:
A torn rotator cuff may require physical therapy and orthopedic consultation but may not require the same level of multidisciplinary collaboration as a spinal cord injury.
Choice C Reason:
Acute appendicitis typically involves surgical intervention but may not require the same degree of ongoing interprofessional collaboration as other complex conditions.
Choice D Reason:
A urinary tract infection is a common and relatively straightforward condition that is usually managed by nurses and primary care providers without extensive interprofessional conferences.
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