How it Works
Try Naxlex NCLEX-RN (Free-Trial)

Chest x-ray: Consolidation in the right lower lobe consistent with pneumonia Review H and P, nurse's notes, flow sheet, doctor's order, and Imaging studies.

What statements indicate the client's confusion is resolving?

Select all that apply.

A.

Asks how long he has been in the hospital

B.

Drinking broth

C.

States he is hungry

D.

Clawing at the air

E.

Keeps trying to get out of bed to find the swimming pool

F.

Recognizes his daughter

G.

Oriented to time, place, and self

H.

Oxygen saturation on 0.5L of 100%

Answer and Explanation

Correct Answer : A,B,C,F,G

Based on the given information, the statements that indicate the client's confusion is resolving are:

  • Asks how long he has been in the hospital: This shows cognitive awareness and the ability to ask relevant and coherent questions.
  • States he is hungry: This indicates a return to normal appetite and the ability to recognize and express basic needs.
  • Recognizes his daughter: This demonstrates the ability to recognize and identify a familiar individual, suggesting an improved level of cognitive functioning.
  • Oriented to time, place, and self: Being aware of the current time, location, and personal identity reflects an improved level of orientation and mental clarity.

  • The statement "Drinking broth" does  reflect the client's willingness and ability to consume food.

The following statements suggest ongoing confusion or potential issues:

  • Clawing at the air: This behavior may indicate restlessness, agitation, or disorientation.
  • Keeps trying to get out of bed to find the swimming pool: This behavior may indicate confusion or an altered perception of reality.

The statement "Oxygen saturation on 0.5L of 100%" provides information about the client's oxygen saturation level but does not specifically address the resolution of confusion.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

A. "Are you planning to obey the voices?" – This question is crucial as it assesses the immediate risk of harm to the client or others. Determining if the client intends to follow commands from hallucinations provides insight into potential danger, ensuring safety is prioritized.

B. "Have you taken any hallucinogens?" – While drug use can contribute to hallucinations, asking about substance use is less urgent than assessing potential harm from the voices. Immediate safety takes precedence over exploring potential causes at this stage.

C. "When did these voices begin?" – Knowing when the symptoms started is relevant for understanding the history of the hallucinations but is secondary to determining if the client intends to act on any commands from the voices, as safety is the first priority.

D. "Do you believe the voices are real?" – This question helps assess the client’s insight into the hallucinations but is not as critical as assessing the immediate risk of harm by determining if the client plans to follow any commands from the voices.

Correct Answer is C

Explanation

Accommodation refers to the ability of the eyes to adjust and focus on objects at different distances. When a client's pupils constrict as they change focus from a far object to a near object, it indicates that their pupils are reacting appropriately to accommodate the change in focus.

To document this finding accurately, the practical nurse (PN) should document "Pupils reactive to accommodation." This statement captures the observation that the pupils are constricting in response to the client changing their focus from a far object to a near object. It indicates normal pupillary response and accommodation.

Let's briefly evaluate the other options:

A. Consensual pupillary constriction present.

Consensual pupillary constriction refers to the simultaneous constriction of both pupils when light is shone into one eye. This finding is not directly related to accommodation or the client's change in focus.

Therefore, it is not the appropriate documentation for the given scenario.

B. Nystagmus present with pupillary focus.

Nystagmus refers to involuntary eye movements that can affect the alignment and focus of the eyes. The presence of nystagmus is not mentioned in the scenario, and it is not directly related to the client's change in focus. Therefore, it is not the appropriate documentation for the given scenario.

D. Peripheral vision intact.

Peripheral vision refers to the ability to see objects outside the central visual field. While important for assessing visual function, it is not directly relevant to the observed pupillary response during accommodation. Therefore, it is not the appropriate documentation for the given scenario.

In summary, when a client's pupils constrict as they change focus from a far object to a near object, the practical nurse should document "Pupils reactive to accommodation" to accurately describe the observed pupillary response during the accommodation process.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register