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 recommended weight gain during pregnancy can vary depending on a woman's pre-pregnancy BMI (Body Mass Index).
For a client with a prepregnancy BMI of 30.5, the recommended weight gain is approximately 11 to 20 pounds. Therefore, none of the options A, B, C, are within this recommended range.
So, the nurse should inform the client that an acceptable weight gain for her would be between 11 to 20 pounds during her pregnancy.
Correct Answer is C
Explanation
Choice A Reason:
Increasing the flow rate without healthcare provider guidance can be dangerous and should not be done without proper instruction.
Choice B Reason:
Synthetic blankets can generate static electricity, which poses a fire hazard in the presence of oxygen. Clients using oxygen therapy should be advised to use cotton or wool blankets that are less likely to generate static.
Choice C Reason:
"I will check my oxygen equipment at least once daily." This statement indicates an understanding of the importance of equipment safety and maintenance in home oxygen therapy. Regularly checking oxygen equipment for proper functioning is essential for the client's safety. It helps ensure that the oxygen delivery system is working correctly and that there are no issues with flow rate or oxygen concentration.
Choice D Reason:
Isopropyl alcohol is flammable and should not be used to clean oxygen equipment due to the risk of ignition in the presence of oxygen. Clients should use mild soap and water for cleaning nasal cannulas and other equipment.
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