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. Insertion of a nasogastric tube B. Administration of an iron injection using Z-track technique C. Irrigation of a wound with antibiotic solution D. Placement of a central venous catheter

Correct Answer is D

Explanation

A. Insertion of a nasogastric tube: While informed consent is important for many procedures, the insertion of a nasogastric (NG) tube is generally considered a routine procedure that may not require formal informed consent unless specific complications or risks are involved.

B. Administration of an iron injection using Z-track technique: Informed consent is typically required for procedures with inherent risks or invasive elements, but routine administration of iron injections is not typically classified as needing informed consent, unless there are specific concerns.

C. Irrigation of a wound with antibiotic solution: Irrigation of a wound is typically a low-risk procedure, and although it is important to inform the client about the treatment, it generally does not require formal informed consent unless there are complications or risks involved.

D. Placement of a central venous catheter: Informed consent is required for the placement of a central venous catheter, as it is an invasive procedure with potential risks such as infection, bleeding, and damage to blood vessels. This procedure requires the nurse to obtain and document the client's consent before proceeding.

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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 reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Correct Answer is D

Explanation

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