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A nurse is caring for an older adult client who is postoperative.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.

Answer and Explanation

The Correct Answer is []

Condition: Delirium.

2 actions:

Encourage family members to stay with the client,

Monitor the client's fluid intake and output.

2 parameters:

Fall risk,

Sleep-wake cycle.

Rationale for correct condition: Delirium is indicated by the sudden onset of disorientation, confusion, and changes in mental status. Postoperative status, dehydration, and infection contribute to delirium. The client's symptoms began recently and are acute. Delirium often presents with restlessness and disturbed sleep. Immediate intervention is crucial to prevent further deterioration.

Rationale for actions: Family presence provides reassurance and helps reorient the client. Familiar faces can reduce anxiety and confusion. Monitoring fluid intake and output addresses dehydration, a common delirium trigger. Ensuring proper hydration can improve mental status. Identifying coping skills is less urgent in acute delirium. Encouraging exercise is inappropriate until the client stabilizes.

Rationale for parameters: Monitoring fall risk is crucial due to the client's confusion and agitation. Preventing falls ensures safety. Tracking the sleep-wake cycle helps assess delirium severity and improvement. Delirium often disrupts sleep patterns. Suicidal ideation is less likely related to delirium. Weight loss is not an immediate concern. Oxygen saturation is stable, irrelevant for delirium.

Rationale for incorrect conditions: Depression presents with prolonged low mood, not sudden confusion. Alzheimer's disease involves gradual cognitive decline, unlike acute delirium. Generalized anxiety disorder does not explain acute disorientation and restlessness.

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Correct Answer is A

Explanation

Choice A rationale

A fluctuating level of orientation is a hallmark sign of delirium. Delirium is characterized by an acute and fluctuating course of altered mental status, including changes in attention, awareness, and cognition.

Choice B rationale

A consistent state of depression is not indicative of delirium. While depression can affect mental status, it does not typically present with the acute, fluctuating changes seen in delirium.

Choice C rationale

Demonstrating obsessive behaviors is more characteristic of obsessive-compulsive disorder and does not typically indicate delirium.

Choice D rationale

Short-term memory loss can be a feature of many conditions, including dementia, but does not specifically indicate delirium, which is distinguished by its rapid onset and fluctuating nature. .

A. Place a lock at the top of doors leading outside. B. Use light restraints while the client is in bed. C. Administer an antianxiety medication before bedtime. D. Encourage the client to nap during the day.

Correct Answer is A

Explanation

Choice A rationale

Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety.

Choice B rationale

Using light restraints is not recommended due to ethical concerns and potential harm.

Choice C rationale

Administering antianxiety medication should not be the first strategy due to potential side effects and over-medication.

Choice D rationale

Encouraging napping during the day may worsen nighttime wakefulness and wandering.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

Explanation

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