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 D

Explanation

Choice A Reason: The burned area is yellow in color with severe edema is not a finding of a deep partial-thickness burn, but a superficial partial-thickness burn. A superficial partial-thickness burn involves the epidermis and the upper layer of the dermis, causing pain, redness, swelling, and blistering.

Choice B Reason: The burned area is black in color and pain is absent is not a finding of a deep partial-thickness burn, but a full-thickness burn. A full-thickness burn involves the epidermis, dermis, and underlying tissues, causing necrosis, charred skin, and loss of sensation.

Choice C Reason:This description aligns with a superficial partial-thickness (first-degree or mild second-degree) burn rather than a deep partial-thickness burn. Superficial partial-thickness burns involve the epidermis and the upper portion of the dermis. These burns appear pink or red, often accompanied by moisture and blister formation due to fluid leakage from damaged capillaries. They are painful because nerve endings remain intact. Healing occurs within 10 to 21 days without significant scarring.

Choice D Reason:Deep partial-thickness burns extend deeper into the dermis, damaging a larger portion of skin structures, including sweat glands and hair follicles. These burns typically appear red or white and may have a soft eschar (dead tissue), which differentiates them from more superficial burns that do not develop eschar. Unlike full-thickness burns, nerve endings remain partially intact, so the patient may still experience some pain. These burns take more than 21 days to heal and often require skin grafting to prevent complications such as contractures or hypertrophic scarring.

A. Provide written materials and visual aids B. Use American Sign Language C. Shout at the client from 6 inches away D. Speak to the client in an everyday conversational tone

Correct Answer is D

Explanation

Choice A Reason: Providing written materials and visual aids is not necessary for a client who has hearing at 15 dB, which is considered normal hearing. Normal hearing ranges from 0 to 20 dB, meaning that the person can hear sounds that are as faint as 20 dB or less.

Choice B Reason: Using American Sign Language is not appropriate for a client who has hearing at 15 dB, which is considered normal hearing. American Sign Language is a form of communication that uses hand gestures, facial expressions, and body movements to convey meaning. It is mainly used by people who are deaf or hard of hearing.

Choice C Reason: Shouting at the client from 6 inches away is not advisable for a client who has hearing at 15 dB, which is considered normal hearing. Shouting can be perceived as rude or aggressive, and can damage the hearing of both the speaker and the listener.

Choice D Reason: Speaking to the client in an everyday conversational tone is the best action for a client who has hearing at 15 dB, which is considered normal hearing. Conversational speech ranges from 40 to 60 dB, meaning that the person can hear sounds that are as loud as 60 dB or less.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

The results of a client's audiogram indicate that the client has hearing at 15 decibels (dB). What action should the nurse take when communicating to the client?

Correct Answer is D

Explanation

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