A young man with malaria spikes a temperature of 105°F (40.5°C) and begins to hallucinate. How should the nurse assess this?
Delirium
Psychotic break
Possible stroke
Anxiety disorder
The Correct Answer is A
A. Delirium: Delirium is characterized by acute confusion, disorientation, and altered mental status often due to severe infection or high fever.
B. Psychotic break: While hallucinations are a symptom, a psychotic break is generally a chronic mental health condition rather than an acute response to infection.
C. Possible stroke: Stroke symptoms usually involve sudden onset of neurological deficits rather than fever and hallucinations.
D. Anxiety disorder: Anxiety disorders do not typically cause such high fevers or acute hallucinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The darker the patient's skin, the easier it is to assess for color change. Darker skin can make it more challenging to assess color changes, such as pallor or cyanosis.
B. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation. Palpation can help detect changes in texture and warmth, which might be less visible on darker skin.
C. Pallor in black-skinned individuals will appear as a pale pink color. Pallor in dark-skinned individuals often appears as an ashen or gray color, not pink.
D. Baseline skin color should be assessed in areas with the most pigmentation. Baseline skin color should be assessed in normally less pigmented areas like palms and soles for accurate assessment.
Correct Answer is C
Explanation
A. "I wouldn't need to drink if I had my family back." This statement shifts the focus from personal responsibility for drinking to external factors.
B. "My drinking helps me cope with the stress of my job." This indicates a belief in using alcohol as a coping mechanism rather than recognizing the impact of drinking itself.
C. "All my difficulties are related to my drinking." Recognizing that difficulties are related to drinking shows insight and a step towards taking responsibility for the problem.
D. “I drink because I'm lonely.” While this indicates awareness of a trigger, it does not demonstrate the same level of insight into the central role of drinking in the patient’s difficulties.
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