An 84-year-old patient has just returned from the post-anesthetic care unit after undergoing hip arthroplasty. The patient is only oriented to their name.
The patient’s family is distressed because the patient had no cognitive deficits before surgery.The patient is later diagnosed with postoperative delirium. What should the nurse communicate to the patient’s family?

This type of delirium is treatable and the patient’s cognition will return to its previous levels.

This issue can be resolved by administering antidotes to the anesthetic used in surgery.

Delirium involves a progressive decline in memory loss and overall cognitive function.

This problem is self-limiting and there is nothing to worry about.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Postoperative delirium is a common condition that can occur in older patients after surgery, especially major procedures like hip arthroplasty. It is characterized by a sudden onset of confusion and altered consciousness. This type of delirium is indeed treatable and most patients’ cognition will return to its previous levels. The treatment often involves addressing the underlying causes, such as pain, medication effects, or metabolic imbalances, and providing supportive care. It’s important for the family to understand that this is a temporary condition and does not indicate a permanent change in their loved one’s mental status.
Choice B rationale
While anesthetics can contribute to postoperative delirium, the condition is usually multifactorial and not solely due to the anesthetic used in surgery. Therefore, administering antidotes to the anesthetic is not typically how postoperative delirium is managed. Instead, the focus is on treating the underlying causes and providing supportive care.
Choice C rationale

Delirium does involve a disturbance in cognition, including memory impairment, but it does not involve a progressive decline in memory loss and overall cognitive function. That description is more characteristic of dementia, a different condition. Delirium is typically a temporary condition that improves once the underlying cause is addressed.
Choice D rationale
While postoperative delirium is often self-limiting, meaning it resolves on its own over time, it is not accurate to say there is nothing to worry about. Postoperative delirium can be distressing for the patient and their family, and in some cases, it can be associated with longer hospital stays and increased morbidity. Therefore, it is a condition that should be taken seriously and managed appropriately.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice B rationale
If a patient states that he cannot see the top of the Snellen chart, the nurse should determine whether the patient can count fingers. If the patient is unable to read the top line of the Snellen

chart at 6 meters, the nurse can reduce the distance to 3 meters from the Snellen chart. If the patient still cannot read the chart, the nurse can then determine whether the patient can count fingers.
Choice A rationale
While documenting findings is an important part of the nursing process, it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice C rationale
Obtaining a tumbling E chart to assess visual acuity could be considered if the patient is unable to read letters or numbers, but it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice D rationale
Completing an internal eye exam would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.

A. Instruct the client on daily muscle stretching. B. Order a low-residual diet. C. Encourage the client to void every hour. D. Provide total assistance with all activities of daily living.

Correct Answer is A

Explanation

Choice A rationale
Instructing the client on daily muscle stretching can help alleviate and relax muscle spasms, which is beneficial for a client diagnosed with multiple sclerosis.

Choice B rationale
Ordering a low-residual diet is not typically a part of the care plan for a client diagnosed with multiple sclerosis.
Choice C rationale
Encouraging the client to void every hour may not be necessary for a client diagnosed with multiple sclerosis, unless there are specific urinary symptoms present.
Choice D rationale
Providing total assistance with all activities of daily living may not be necessary for a client diagnosed with multiple sclerosis, as the level of assistance required can vary greatly depending on the severity of the disease.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart. What action should the nurse take?

Correct Answer is B

Explanation

The nurse is creating a plan of care for a client who has a recent diagnosis of multiple sclerosis. Which of the following should the nurse include in the client’s care plan?

Correct Answer is A

Explanation

A nurse is administering a 350 mL unit of PRBCs over 3 hours to a client diagnosed with anemia. The nurse should set the IV pump to deliver how many mL/hr?

A client has informed the Home Health Nurse that they recently noticed distortions when looking at the Amsler grid kept on their refrigerator. What is the appropriate action for the nurse to take?

While waiting for an appointment in the doctor’s office, a patient experiences a convulsive seizure. The nurse is immediately notified. What nursing care should be provided at this time? (Select all that apply.)

The nurse is educating a patient who has been newly prescribed eye medications to treat glaucoma. How can the nurse best determine if the patient can safely and effectively self-administer the medications?

A nurse is working with the family of a patient diagnosed with Alzheimer’s disease to develop an appropriate plan of care. Which of the following would the nurse suggest to foster socialization?

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?

A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

A nurse is caring for a patient who experiences severe cluster headaches. At what point in the course of a new headache should the patient be instructed to take medications?