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 B
Explanation
Choice A Reason:
Illusions typically involve misperceptions of sensory stimuli and can occur in various mental health conditions but are not specific to dementia.
Choice B Reason:
Memory loss that disrupts ADLs is correct. Memory loss that disrupts activities of daily living (ADLs) is a common and characteristic finding in individuals with dementia. Dementia is a progressive neurological disorder that affects cognitive function, including memory. As it progresses, individuals with dementia often experience increasing difficulty with memory and daily functioning.
Choice C Reason:
Pressured speech is a symptom often seen in conditions like mania or bipolar disorder but is not typically associated with dementia.
Choice D Reason:
Catatonia is a neuropsychiatric syndrome that can occur in conditions like schizophrenia but is not a common feature of dementia.
Correct Answer is D
No explanation
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