An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia.
Which of the following is the best reason for the assessment findings?
Mood disorder.
Sensory deprivation.
Anxiety.
Cerebral vascular accident (CVA).
The Correct Answer is B
Sensory deprivation is a condition in which a person experiences a lack of sensory input or stimulation.
This can result from isolation, confinement, or loss of sensory function. Sensory deprivation can cause psychological and physiological changes, such as irritability, confusion, paranoia, hallucinations, depression, anxiety, and cognitive impairment.
Choice A is wrong because mood disorder is a general term for a group of mental health conditions that affect a person’s emotional state, such as depression, bipolar disorder, or anxiety disorder. Mood disorder is not likely to be caused by isolation precautions for C diff.
Choice C is wrong because anxiety is a feeling of nervousness, worry, or fear that interferes with daily functioning. Anxiety can be triggered by stress, trauma, or other factors, but it is not a direct consequence of isolation precautions for C diff.
Choice D is wrong because cerebral vascular accident (CVA), also known as stroke, is a sudden interruption of blood flow to the brain that causes neurological damage. CVA can cause symptoms such as weakness, numbness, slurred speech, vision loss, or confusion, but it is not related to isolation precautions for C diff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client bears weight on both feet when moving the walker ahead and steps with the weaker leg first. This is the proper way to use a walker for ambulation, as it provides stability and reduces stress on the affected joints.
Choice A is wrong because the client should not look down at his feet to prevent falling, but rather look ahead at where he is going. Looking down can cause neck strain and loss of balance.
Choice C is wrong because the client should not place her full weight on the walker with her arms while taking steps, as this can cause upper extremity fatigue and injury. The client should use the walker as a support, not a crutch.
Choice D is wrong because the client should not lean forward at a 60-degree angle while stepping into the walker, as this can cause back pain and poor posture. The client should stand upright and move the walker forward about one step’s length at a time.
Correct Answer is D
Explanation
A weak, rapid pulse indicates that the client is experiencing hypovolemia or low blood volume due to blood loss during surgery.
The nurse should recommend to the provider to administer intravenous fluids to restore the client’s circulating volume and improve their hemodynamic status.
Choice A is wrong because anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter that stimulates the parasympathetic nervous system.
Anticholinergics can cause tachycardia, dry mouth, urinary retention, and blurred vision. They are not indicated for hypovolemia.
Choice B is wrong because urinary catheter placement is not a priority intervention for a client with hypovolemia.
Urinary catheterization can help monitor urine output and renal perfusion but does not address the underlying cause of low blood volume.
Choice C is wrong because beta blockers are drugs that block the action of epinephrine and norepinephrine, neurotransmitters that stimulate the sympathetic nervous system.
Beta-blockers can lower blood pressure, heart rate, and cardiac output.
They are not indicated for hypovolemia and can worsen the client’s condition.
To communicate this information using the SBAR tool, the nurse should follow these steps: Situation: Identify yourself, the client, and the problem.
For example: “I am (name), the nurse caring for (client name) in room (number).
I am calling because I am concerned that the client has developed hypovolemia after surgery.”
Background: Provide relevant and brief information related to the situation.
For example: “The client had a surgical procedure (name and type) at (time) today. They have lost (amount) of blood during and after surgery.
Their current vital signs are: blood pressure (value), pulse (value), respiratory rate (value), temperature (value), oxygen saturation (value).”
Assessment: Share your analysis and considerations of options. For
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