After performing a neurological assessment, the student nurse shares the following findings with the primary nurse: Visual fields full to confrontation with Intact extraocular movements. No nystagmus, midline protrusion of tongue, and negative Romberg test. Which of the following will the primary nurse tell the student nurse to document?

Abnormal visual fields, abnormal motor assessment

Normal neurological assessment findings

Normal visual but abnormal cranial nerves IXII

Normal visual fields, abnormal motor assessment

Answer and Explanation

The Correct Answer is B

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Correct Answer is A

Explanation

Identify the underlying cause. This is correct because delirium is a reversible condition that is often caused by an underlying medical problem, such as infection, medication, or dehydration.

Identifying and treating the cause can help resolve the delirium and prevent further complications.

Tell the client that hallucinations are not real. This is incorrect because it can increase the client's anxiety and confusion. The nurse should acknowledge the client's feelings and perceptions, but not reinforce or argue with them.

Speak slowly and clearly. This is incorrect because it is not the best first action. While speaking slowly and clearly can help communicate with the client, it does not address the root cause of the delirium.

Request the assistance of physical therapy. This is incorrect because it is not relevant to the question. Physical therapy may be helpful for some clients with delirium, but it is not a priority intervention.

A. Encourage the use of the wide grip utensils. B. Remind the client to look for food on the left side of the tray C. Provide a nonskid mat to alleviate plate movement D. Encourage the client to use his right hand when feeding himself

Correct Answer is B

No explanation

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Naxlex Comprehensive Predictor Exams

According to the ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?

Correct Answer is A

Explanation

A nurse caring for a client who had a rightsided stroke and is exhibiting homonymous hemlanopsia when eating. Which of the following actions should the nurse take?

Correct Answer is B

The nurse caring for a client with a brain tumor will monitor for which of the following early signs of increased intracranial pressure?

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

A nurse receives a postsurgical endarterectomy client, what is the priority action for the nurse to take?

A client is extremely drowsy, minimally responsive, and has a difficult time following commands. With vigorous stimulation the client awakens but quickly falls back asleep. What level of consciousness does this describe?

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?