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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 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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:
Halitosis (bad breath) is not typically associated with a decreased CD4-T-cell count.
Choice B rationale:
Gingivitis (gum inflammation) is not directly related to a decreased CD4-T-cell count.
Choice C rationale:
Candidiasis (a fungal infection) is common in individuals with AIDS due to their weakened immune system.
Choice D rationale:
Xerostomia (dry mouth) is not typically associated with a decreased CD4-T-cell count.

A. It is primarily transmitted through direct contact with infected body fluids. B. It is primarily transmitted through mosquitoes. C. It is primarily transmitted through casual contact. D. It is primarily transmitted through accidental puncture wounds.

Correct Answer is A

Explanation

Choice A rationale:
HIV is primarily transmitted through direct contact with infected body fluids, such as blood, semen, vaginal fluids, and breast milk. This can occur during unprotected sex, sharing of needles, or from mother to child during childbirth or breastfeeding.
Choice B rationale:
Mosquitoes do not transmit HIV. The virus does not replicate or survive well within insects.
Choice C rationale:
Casual contact, such as hugging, shaking hands, or sharing dishes, does not lead to HIV transmission.
Choice D rationale:
Accidental puncture wounds can potentially transmit HIV, but this is not the primary mode of transmission. It’s more common in healthcare settings where workers might be exposed to needlestick injuries.

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Incorrect Choices and Explanations:

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

Correct Answer is C

Explanation

A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

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