An elderly client presents to the emergency room with a family member. The family member reports that the elderly client has been vomiting and not eating or drinking for 2 days. This morning the elderly client became confused, which is new. The nurse knows the elderly client probably has which of the following?
Delirium
New onset Alzheimer's disease
New onset Huntington's disease
New onset Parkinson's disease
The Correct Answer is A
A. Delirium is an acute, temporary state of confusion, often caused by factors such as dehydration, infection, or metabolic disturbances. In this case, the elderly client’s confusion following vomiting and not eating or drinking for 2 days suggests that dehydration or an underlying illness is likely causing the delirium.
B. Alzheimer's disease is a progressive, degenerative condition that leads to chronic memory loss and cognitive decline. It does not typically cause sudden confusion, as seen in this case.
C. Huntington's disease is a genetic neurodegenerative disorder that causes motor dysfunction and cognitive decline. It does not present suddenly with confusion in an elderly client.
D. Parkinson's disease is a progressive neurological disorder that primarily affects motor function, causing tremors, rigidity, and bradykinesia. It does not typically present with sudden confusion or the symptoms described in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Turn the client to the side is the correct action to prevent aspiration, but restraining the client is not appropriate. Restraint can cause injury and should never be used during a seizure. The client should be allowed to move freely during the seizure, and positioning them on their side helps maintain an open airway and prevent aspiration.
B. Time the duration of the seizure is essential for monitoring the length of the seizure. This helps the nurse determine if the seizure is prolonged or if medical intervention is necessary.
C. Administer supplemental oxygen to the client is appropriate if the client is experiencing apnea or breathing difficulties during the seizure. The nurse should ensure the oxygen equipment is ready and functioning to provide supplemental oxygen if needed.
D. Placing a tongue depressor in the client's mouth is not recommended during a seizure. This can cause injury to the client’s mouth, teeth, or airway and does not prevent biting the tongue. Instead, the nurse should focus on protecting the client's airway and preventing aspiration.
Correct Answer is C
Explanation
A. A cervical collar is not necessary for a lumbar laminectomy. A cervical collar is used for neck surgeries or spinal cord injuries involving the cervical spine, not for lumbar procedures.
B. The head of the bed elevated 30 degrees may be appropriate for certain conditions, but after a lumbar laminectomy, it is typically recommended to keep the head of the bed flat or slightly elevated to reduce pressure on the spine.
C. Logrolling the client every 2 hr is the correct action. After a lumbar laminectomy, the nurse should use the logroll technique to turn the patient to prevent strain on the spine and promote proper healing.
D. Supine with her arms elevated on pillows is not the best position. While elevation of the arms may be helpful for comfort, the focus should be on protecting the lumbar spine and ensuring proper positioning to prevent strain.
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