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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 B

Explanation

Choice A rationale:
Seeing bright flashes of light and floaters is typically associated with retinal detachment, not cataracts.
Choice B rationale:
Having a decreased ability to perceive colors is a common symptom of cataracts.
Choice C rationale:
Loss of central vision is typically associated with macular degeneration, not cataracts.
Choice D rationale:
Having a loss of peripheral vision is typically associated with glaucoma, not cataracts.

A. Basal cell carcinoma. B. Squamous cell carcinoma. C. Malignant melanoma. D. Actinic keratosis.

Correct Answer is A

Explanation

Choice A rationale:
Basal cell carcinoma often presents as a raised, flesh-colored lesion with pearly white borders. This is the most common type of skin cancer.
Choice B rationale:
Squamous cell carcinoma typically appears as a firm, red nodule or a flat lesion with a scaly, crusted surface, not a raised, flesh-colored lesion with pearly white borders.
Choice C rationale:
Malignant melanoma is usually a large brownish spot with darker speckles, not a raised, flesh-colored lesion with pearly white borders.
Choice D rationale:
Actinic keratosis appears as rough, scaly patches on sun-exposed areas of the skin, not a raised, flesh-colored lesion with pearly white borders.

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Incorrect Choices and Explanations:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report.

Correct Answer is B

Explanation

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Correct Answer is A

Explanation

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include?

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

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