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 []

Potential Condition: Delirium The client’s symptoms such as disorientation to time and place, disorganized thinking, lack of attention, rambling speech, and changes in behavior that began the prior evening suggest the client is most likely experiencing delirium12. Delirium is common in older adults who are postoperative and can be triggered by factors such as dehydration, infection, and certain medications.

Actions to Take:

Choice A: Monitor client’s fluid intake and output The client has refused to eat or drink since the previous day and has a significant difference between intake (250 mL) and output (2,500 mL), suggesting possible dehydration3. Monitoring the client’s fluid intake and output can help assess the client’s hydration status and the effectiveness of interventions such as IV fluid administration.

Choice E: Encourage family members to stay with the client Family members can provide a familiar and reassuring presence, which can help orient the client and potentially reduce agitation and restlessness. They can also provide valuable information about the client’s normal behavior and any changes they have noticed.

Parameters to Monitor:

Choice A: Fall risk The client is attempting to get out of bed without assistance, which increases the risk of falls4. Monitoring the client’s mobility and implementing fall prevention strategies is crucial.

Choice E: Sleep-wake cycle The client has been awake most of the night, indicating a disruption in the sleep-wake cycle5. Monitoring the client’s sleep patterns can provide information about the progression of delirium and the effectiveness of interventions.

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Correct Answer is C

Explanation

Choice A Reason:
Repeating orientation questions until the client gives a correct response is not an effective strategy for managing dementia. Clients with dementia often have memory impairments and may not be able to provide the correct response even after repeated questioning. This approach can lead to frustration and anxiety for the client. Instead, the nurse should use gentle reminders and cues to help orient the client without causing stress.

Choice B Reason:
Providing the client with a dark environment for sleeping is generally a good practice for promoting sleep hygiene. However, in the context of dementia care, it is not the most critical action. Clients with dementia may experience confusion and disorientation, especially in the dark. It is important to ensure that the environment is safe and that there is adequate lighting to prevent falls and injuries.

Choice C Reason:
Making a personal introduction to the client at each interaction is crucial in dementia care. Clients with dementia may have difficulty recognizing people, including caregivers. By introducing themselves each time, nurses can help reduce confusion and anxiety for the client. This practice also helps build trust and rapport, which are essential for effective care.

Choice D Reason:
Giving the client a list of foods to choose from for dinner can be beneficial in promoting autonomy and independence. However, clients with dementia may have difficulty making decisions and may become overwhelmed by too many choices. It is better to offer a limited number of options or to present the choices one at a time to make the decision-making process easier for the client.

A. Agree to a prescription for an alcohol use deterrent. B. Form a close support network. C. Acknowledge an inability to control drinking. D. Incorporate a form of spirituality into daily life.

Correct Answer is C

Explanation

Choice A Reason:
Agreeing to a prescription for an alcohol use deterrent, such as disulfiram or naltrexone, can be an effective part of a comprehensive treatment plan for alcohol use disorder. These medications help reduce cravings and the pleasurable effects of alcohol, making it easier for individuals to maintain sobriety. However, agreeing to take medication is not typically considered the first step in recovery. The initial step involves recognizing and admitting the problem, which sets the foundation for all subsequent treatment efforts.

Choice B Reason:
Forming a close support network is crucial for long-term recovery from alcohol use disorder. Support networks provide emotional support, accountability, and practical assistance, which are essential for maintaining sobriety. These networks can include family, friends, support groups, and healthcare professionals. While forming a support network is vital, it is not the first step. The first step is acknowledging the problem, which then allows the individual to seek and accept support.

Choice C Reason:
Acknowledging an inability to control drinking is the first and most critical step toward successful recovery from alcohol use disorder. This step aligns with the first step of the 12-step program used by Alcoholics Anonymous, which involves admitting powerlessness over alcohol. Recognizing the problem is essential because it opens the door to seeking help and engaging in treatment. Without this acknowledgment, individuals are unlikely to commit to the recovery process or utilize available resources effectively.

Choice D Reason:
Incorporating a form of spirituality into daily life can provide significant benefits during the recovery process. Spirituality can offer a sense of purpose, connection, and inner peace, which can be particularly helpful in overcoming addiction. Many recovery programs, including 12-step programs, emphasize the importance of spirituality. However, while spirituality can enhance recovery, it is not the initial step. The first step is recognizing and admitting the inability to control drinking.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?

A nurse is assisting in the care of a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take to promote a therapeutic environment?

A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?

A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?

A nurse is collecting data from a client who reports drinking alcoholic beverages daily but has not consumed alcohol in the last 24 hours. Which of the following findings should the nurse identify as a manifestation of alcohol withdrawal?