A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following in the health record should the nurse identify as a cause of this disorder?

Seasonal allergies

History of GERD

Benzodiazepines

Completed antibiotics 10 days ago

Answer and Explanation

The Correct Answer is C

Choice A Reason: Seasonal allergies are not a cause of delirium, but a common condition that affects the respiratory system and causes symptoms such as sneezing, runny nose, itchy eyes, or coughing.

Choice B Reason: History of GERD is not a cause of delirium, but a chronic condition that affects the digestive system and causes symptoms such as heartburn, regurgitation, chest pain, or difficulty swallowing.

Choice C Reason: Benzodiazepines are a cause of delirium, especially in older adults or those with cognitive impairment. Benzodiazepines are a class of drugs that act on the central nervous system and cause sedation, relaxation, and reduced anxiety. However, they can also impair memory, attention, orientation, and judgment, and lead to confusion, agitation, hallucinations, or delusions.

Choice D Reason: Completed antibiotics 10 days ago are not a cause of delirium, but a treatment for bacterial infections. Antibiotics can have side effects such as nausea, diarrhea, rash, or allergic reactions, but they do not cause delirium unless they are toxic or interact with other medications.

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Correct Answer is A

Explanation

Choice A reason: This is the correct answer because the Amsler grid test is performed to diagnose macular degeneration. The Amsler grid is a pattern of straight lines with a dot in the center. The client is asked to look at the dot and report any distortions or missing areas in the grid. This can indicate damage to the macula, which is the central part of the retina that provides sharp vision.

Choice B reason: This is incorrect because the Snellen chart test is not performed to diagnose macular degeneration. The Snellen chart is a chart of letters of different sizes that are read from a distance. The client is asked to read the smallest line they can see clearly. This can indicate visual acuity or sharpness of vision, but not macular degeneration.

Choice C reason: This is incorrect because the intraocular pressure test is not performed to diagnose macular degeneration. The intraocular pressure test measures the pressure inside the eye using a device called a tonometer. The client may feel a puff of air or a gentle touch on their eye. This can indicate glaucoma, which is a condition where increased pressure damages the optic nerve, but not macular degeneration.

Choice D reason: This is incorrect because the refraction test is not performed to diagnose macular degeneration. The refraction test measures how well the eye bends light rays using a device called a phoropter. The client looks through different lenses and reports which ones make their vision clearer. This can indicate refractive errors such as nearsightedness, farsightedness, or astigmatism, but not macular degeneration.

A. Request the charge nurse put the client on the surgery schedule B. Document the WBC count from the morning labs C. Notify the healthcare provider D. Provide an antiemetic

Correct Answer is C

Explanation

Choice A Reason: Requesting the charge nurse put the client on the surgery schedule is not the best first action, as it does not address the urgency of the situation. The client may have a perforated appendix, which is a life-threatening complication that requires immediate intervention.

Choice B Reason: Documenting the WBC count from the morning labs is not the best first action, as it does not address the client's current condition. The WBC count may be elevated due to inflammation or infection, but it does not indicate the severity of the problem.

Choice C Reason: This is the correct choice. Notifying the healthcare provider is the best first action, as it alerts them to the possibility of a perforated appendix and allows them to order appropriate tests and treatments.

Choice D Reason: Providing an antiemetic is not the best first action, as it does not address the underlying cause of the vomiting. The client may have peritonitis, which is inflammation of the abdominal cavity due to leakage of intestinal contents. An antiemetic may mask this symptom and delay diagnosis and treatment.

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A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following in the health record should the nurse identify as a cause of this disorder?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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