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. Grieving related to loss of son: The recent loss of his son is a significant and primary concern, leading to social withdrawal and other behaviours.
B. Social isolation related to depression: While social isolation is a concern, it stems from the primary issue of grieving.
C. Ineffective coping related to the number of recent losses: Ineffective coping is important but addressing the grieving process is more immediate and central.
D. Hopelessness related to relocation to a nursing home: Hopelessness due to relocation may contribute but is not the immediate primary issue in light of the recent death.
Correct Answer is D
Explanation
A. Each evening: Turning the patient only once per day is insufficient to prevent pressure injuries.
B. Once every shift: This is also inadequate as it does not provide the frequent repositioning necessary to prevent pressure injuries.
C. Every 4 hours: While better than every shift, every 4 hours may still not be frequent enough to prevent pressure injuries in at-risk patients.
D. Every 2 hours: Frequent repositioning, such as every 2 hours, is essential for pressure injury prevention in bedfast patients.
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