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
C, "You can begin collection of urine after discarding your first morning void."
A 24-hour creatinine clearance test is used to evaluate how well the kidneys are functioning by measuring the amount of creatinine in the blood and urine over a 24-hour period. During the test, the client is asked to discard their first morning void and then collect all urine for the next 24 hours.
Option A is incorrect because a protein-rich diet can affect the creatinine levels in the urine, which can result in inaccurate test results. Therefore, the nurse should advise the client to avoid a protein-rich diet during the collection period.
Option B is incorrect because blood glucose levels are not relevant to a 24-hour creatinine clearance test. Therefore, the nurse should not ask the client to record their blood glucose level each time they void.
Option D is incorrect because using an antiseptic towel to cleanse the perineal area can also affect the test results by introducing contaminants into the urine sample. Therefore, the nurse should advise the client to cleanse the perineal area with soap and water or an alcohol wipe.
Correct Answer is A
Explanation
Choice A Reason:
Maintaining the client in high-Fowler's position is a correct action. Keeping the client in a high-Fowler's position (sitting up with the head of the bed elevated) can help improve lung expansion and ease breathing for clients with heart failure and respiratory distress.
Choice B Reason:
Instructing the client to cough every 4 hr. is not directly addressing the underlying issue of fluid accumulation and respiratory distress associated with heart failure. Coughing alone may not be sufficient to alleviate these symptoms.
Choice C Reason:
Increasing the client's intake of oral fluids is generally not recommended without considering the client's overall fluid status. In heart failure, there is often a need to restrict fluid intake to prevent fluid overload and worsening of symptoms. Increasing oral fluids should be done cautiously and under the guidance of the healthcare provider.
Choice D Reason:
Encouraging the client to ambulate to loosen secretions. While ambulation can be beneficial for some clients to improve overall circulation and prevent complications, it may not be the primary intervention in this case. The client's primary issue is likely related to pulmonary congestion due to heart failure, and they may be too short of breath to ambulate effectively.
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