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 A
Explanation
A. Use nightlights and remove extra furniture from the room: Nightlights provide gentle lighting that can reduce disorientation, and removing extra furniture minimizes fall risk.
B. Place the patient in a room with another recovering patient. This might increase agitation and disrupt both patients' sleep.
C. Instruct the patient to orient himself to his surroundings at bedtime. This may not be effective due to the patient's disorientation during detoxification.
D. Wake the patient up every 4 hours to eat a small snack. Frequent waking can disrupt sleep patterns and increase confusion.
Correct Answer is B
Explanation
A. Transport victim to hospital: While transport to the hospital is necessary, it is not the immediate priority when the victim is still on fire.
B. Stop, drop, and roll: The first action for someone whose clothing is on fire is to stop, drop, and roll to extinguish the flames and prevent further burns.
C. Cover victim with clean cloth or sheet: Covering with a clean cloth is important after the flames have been extinguished but not the first step when the victim is still burning.
D. Remove all nonadherent clothing and jewelry: Removing clothing and jewelry should be done after the flames are extinguished and initial care has been administered.
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