A nurse is caring for an older adult client who is postoperative.
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.
The Correct Answer is []
Condition Most Likely Experiencing:
Delirium
- Explanation: The client has acute confusion, disorganized thinking, restlessness, incoherent speech, and altered sleep-wake cycle—all classic signs of delirium. The sudden onset (starting the previous evening) and fever (38.6°C) suggest a potential underlying cause, such as infection or dehydration.
Actions to Take:
Monitor the client's fluid intake and output.
- Explanation: The client has severe fluid imbalance (250 mL intake vs. 2,500 mL output), leading to dehydration, which can contribute to delirium. Monitoring intake and output is critical for managing hydration status.
Encourage family members to stay with the client.
- Explanation: Familiar faces can help reorient the client and reduce agitation. Delirium often improves with familiar environmental cues and reassurance.
Parameters to Monitor:
Sleep-wake cycle.
- Explanation: Disrupted sleep patterns are a key symptom of delirium. Tracking sleep can help assess improvement or worsening of the condition.
Fall risk.
- Explanation: The client is attempting to get out of bed without assistance, which puts them at high risk for falls. Close monitoring is essential to prevent injury.
Incorrect Choices and Explanations:
Request a prescription for benzodiazepine.
- Why Incorrect? Benzodiazepines can worsen delirium, especially in older adults, by increasing confusion and fall risk.
Assist the client to identify coping skills.
- Why Incorrect? Delirium is an acute medical condition, not a psychological disorder. The focus should be on treating the underlying cause, not psychological coping strategies.
Encourage the client to exercise.
- Why Incorrect? The client is confused, weak, and at risk of falls. Exercise is not appropriate at this stage.
BUN level.
- Why Incorrect? While kidney function (BUN) could be affected by dehydration, monitoring fluid balance directly (intake/output) is more immediate and relevant.
Weight loss.
- Why Incorrect? While the client has refused to eat or drink, weight loss occurs over time, whereas the primary concern is acute dehydration and delirium.
Suicidal ideation.
- Why Incorrect? There is no indication of suicidal thoughts. The confusion and agitation are more likely due to delirium than depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hemorrhagic stroke is characterized by sudden, severe headache, vomiting, and a significant increase in blood pressure, all of which are present in the client. This type of stroke occurs when a weakened blood vessel ruptures and bleeds into the surrounding brain.
Choice B rationale:
Thrombotic stroke is caused by a clot that develops in a blood vessel within the brain. It typically presents with less severe symptoms and a gradual onset, not a sudden one.
Choice C rationale:
Embolic stroke is caused by a clot that travels to the brain from another part of the body. Like thrombotic stroke, it typically has a more gradual onset.
Choice D rationale:
Transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain. It usually lasts less than an hour and does not cause permanent damage.
Correct Answer is D
Explanation
Choice A rationale:
Cardiac enzymes do not identify the location of the MI, they are biomarkers that indicate heart muscle injury.
Choice B rationale:
Cardiac enzyme tests do not provide information about the heart’s structure or the mobility of the heart valves. That’s typically assessed using imaging studies like an echocardiogram.
Choice C rationale:
Cardiac enzymes do not assist in diagnosing the presence of pulmonary congestion. They are specific to heart muscle damage.
Choice D rationale:
Cardiac enzymes, such as troponin and creatine kinase, rise when there is damage to the heart muscle, such as in an MI. Therefore, these tests help determine the degree of damage to the heart tissues.
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