A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Alternate daily caregivers.

Remind the client of the day and time often.

Offer the client several choices at mealtimes.

Avoid discussing the client's fears.

Answer and Explanation

The Correct Answer is B

A. Alternate daily caregivers is incorrect. Consistent caregiving is important for clients experiencing delirium to provide stability and reduce confusion. Frequent changes in caregivers can increase anxiety and disorientation.

B. Remind the client of the day and time often is correct. Frequent reminders of the day, time, and orientation help ground the client in reality and reduce confusion. This is an essential part of managing delirium by addressing disorientation and improving cognitive clarity.

C. Offer the client several choices at mealtimes is incorrect. Giving too many choices can lead to overwhelm and confusion in clients with delirium. It is better to offer simple, limited options to avoid stress or difficulty in decision-making.

D. Avoid discussing the client's fears is incorrect. Addressing a client's fears is important in the management of delirium. It is more beneficial to acknowledge and provide reassurance, which can help reduce anxiety and the psychological stress that might exacerbate delirium.

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Correct Answer is C

Explanation

A. Tinnitus is not typically associated with the ingestion of tyramine-rich foods while on tranylcypromine.

B. Hyperglycemia is not a common adverse effect related to tyramine interaction with tranylcypromine.

C. Hypertension is correct. Ingesting tyramine-rich foods (such as aged cheese, cured meats, and fermented foods) while taking tranylcypromine, a monoamine oxidase inhibitor (MAOI), can cause a hypertensive crisis. Tyramine is normally broken down by monoamine oxidase (MAO), and inhibiting this enzyme with tranylcypromine can lead to a dangerous increase in blood pressure.

D. Hematuria is not a known adverse effect of tranylcypromine or the ingestion of tyramine-rich foods.

A. Apply the transdermal patch to either of the client's forearms. B. Remove the old transdermal patch before applying a new one. C. Apply the patch to a clean, hairless area of the client's skin. D. Use sterile gloves to apply and remove transdermal patches. E. Dispose of old transdermal patches in a childproof container.

Correct Answer is ["B","C","E"]

Explanation

A. "Apply the transdermal patch to either of the client's forearms" is incorrect. The nurse should avoid applying the patch to areas with excessive hair, irritation, or broken skin. Common areas include the upper torso (e.g., upper arm, chest, or back).

B. "Remove the old transdermal patch before applying a new one" is correct. To prevent overdose or accidental administration of an additional dose, the nurse should always remove the old patch before applying a new one.

C. "Apply the patch to a clean, hairless area of the client's skin" is correct. This ensures better adhesion and absorption of the medication, as hair and dirt can interfere with the patch's effectiveness.

D. "Use sterile gloves to apply and remove transdermal patches" is incorrect. Standard gloves are sufficient for applying and removing transdermal patches, as they do not need to be sterile.

E. "Dispose of old transdermal patches in a childproof container" is correct. Fentanyl patches should be disposed of properly to avoid accidental exposure or ingestion by children or pets. A childproof container ensures safe disposal.

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A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

Correct Answer is C

Explanation

A nurse is caring for a client who has a new prescription for a fentanyl transdermal patch. Which of the following actions should the nurse take when administering a transdermal patch? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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