A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

Apply soft restraints to wrists and chest.

Administer antipsychotic medications as prescribed.

Administer sedative medications as prescribed.

Arrange for one-on-one observation for the client.

Answer and Explanation

The Correct Answer is D

A. Apply soft restraints to wrists and chest: Using restraints should only be considered as a last resort and should not be the first intervention for managing delirium. Restraints can exacerbate agitation and increase the risk of complications such as skin breakdown, musculoskeletal injury, and psychological distress. Therefore, applying restraints should not be the first action taken by the nurse.

B. Administer antipsychotic medications as prescribed: While antipsychotic medications may be used to manage symptoms of delirium in some cases, they should not be the first intervention for preventing client injury. Additionally, the use of antipsychotics in the ICU requires careful consideration due to potential adverse effects, such as sedation, hypotension, and prolongation of the QT interval. The decision to administer antipsychotic medications should be based on a comprehensive assessment and in consultation with the healthcare team.

C. Administer sedative medications as prescribed: Administering sedative medications may help calm an agitated client with delirium, but it should not be the first intervention for preventing client injury. Sedatives can further impair cognition and increase the risk of falls or other complications. Like antipsychotic medications, the use of sedatives should be based on a thorough assessment and in collaboration with the healthcare team, rather than being the initial action taken by the nurse.

D. Arrange for one-on-one observation for the client: Delirium in the intensive care unit (ICU) is a serious condition that can lead to confusion, disorientation, and an increased risk of injury to the client. The priority intervention for preventing client injury in this situation is to ensure constant monitoring and supervision. By arranging for one-on-one observation, the nurse can provide continuous monitoring of the client's behavior, assess for changes or signs of agitation, and intervene promptly to prevent falls or other injuries.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. "The heart and the coronary arteries weaken, leading to poor perfusion and resulting in angina": This statement is inaccurate. While angina can result from poor perfusion to the heart muscle, it is not typically due to weakening of the heart and coronary arteries. Angina often occurs due to coronary artery narrowing or blockage, leading to reduced blood flow and oxygen delivery to the myocardium.

B. "Coronary arteries become more elastic causing the arteries to stretch as individuals age causing the heart not to receive enough oxygen": This statement is incorrect. Coronary arteries do not become more elastic with age; in fact, they tend to become less elastic due to the development of atherosclerosis, which leads to arterial stiffening and decreased compliance. Atherosclerosis can cause narrowing or occlusion of the coronary arteries, resulting in reduced oxygen delivery to the heart muscle.

C. "Coronary arteries decrease in diameter leading to insufficient blood, oxygen, and nutrients reaching the heart muscle. Manifestations occur due to dilation of coronary arteries with increased blood flow causing increased pressure": This statement is partially incorrect. While it accurately describes the consequences of coronary artery narrowing (decrease in diameter) leading to insufficient blood, oxygen, and nutrient delivery to the heart muscle, the second part of the statement regarding dilation of coronary arteries with increased blood flow causing increased pressure is inaccurate. Coronary artery dilation is a compensatory response to increased demand for oxygen, aiming to improve blood flow to the myocardium. However, dilation alone does not increase pressure in the coronary arteries.

D. "Coronary arteries decrease in diameter leading to insufficient blood, oxygen, and nutrients reaching the heart muscle": This statement is accurate. Coronary artery disease (CAD) involves the progressive narrowing of the coronary arteries due to atherosclerosis, which reduces blood flow to the myocardium. As the arteries narrow, there is insufficient blood, oxygen, and nutrients reaching the heart muscle, leading to manifestations such as angina, myocardial ischemia, and potentially myocardial infarction.

A. Difficulty swallowing B. Shortness of breath C. Exertional fatigue D. Weight gain

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

Explanation

A. Difficulty swallowing: Difficulty swallowing is not typically associated with atrial fibrillation. It may be a symptom of various other conditions such as dysphagia, esophageal disorders, or neurological disorders, but it is not a common manifestation of atrial fibrillation.

B. Shortness of breath: This is the correct answer. Shortness of breath, or dyspnea, is a common symptom of atrial fibrillation. Atrial fibrillation can lead to ineffective atrial contraction, resulting in decreased cardiac output and potential fluid accumulation in the lungs, leading to dyspnea.

C. Exertional fatigue: This is the correct answer. Exertional fatigue, or feeling excessively tired or weak with physical activity, is a common manifestation of atrial fibrillation. Reduced cardiac output and inefficient heart function due to irregular heart rhythms can lead to fatigue, especially during exertion.

D. Weight gain: Weight gain is not typically associated with atrial fibrillation. While some individuals with heart conditions may experience fluid retention and subsequent weight gain, it is not a specific manifestation of atrial fibrillation itself.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has coronary artery disease. Which of the following statements should the nurse include in the teaching to explain the correlation between changes in the coronary arteries and manifestations that occur?

Correct Answer is D

Explanation

A nurse is teaching a client who has symptomatic atrial fibrillation about manifestations to expect. Which of the following should the nurse include in the teaching? (Select All that Apply.)

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

Explanation

A nurse is assessing a client who is experiencing a change in vision. Which of the following statements indicates that the client might be developing cataracts?

A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?

A nurse is teaching a client who has peripheral venous disease about management of symptoms. Which of the following client statements indicates to the nurse an understanding of the teaching?

A nurse is caring for a group of clients. After receiving bedside report, the nurse determines which of the following clients to be at greatest risk for developing delirium?

A nurse is caring for a group of clients with dementia. The nurse recognizes which of the following factors as reasons for the growing numbers of clients diagnosed with dementia in the United States? (Select All that Apply.)

A nurse is teaching a client who has peripheral arterial disease. Which of the following statements should the nurse include in the teaching to explain peripheral arterial disease?

A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply.)

A nurse is teaching a client who has cardiomyopathy about the side effects of their new prescription beta blocker, carvedilol. Which of the following client statements should indicate to the nurse that the client understands the teaching? (select all that apply)