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.
Asks how long he has been in the hospital
Drinking broth
States he is hungry
Clawing at the air
Keeps trying to get out of bed to find the swimming pool
Recognizes his daughter
Oriented to time, place, and self
Oxygen saturation on 0.5L of 100%
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.
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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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A mastectomy is a surgical procedure that involves the removal of all or part of the breast, usually to treat breast cancer. A mastectomy can have a significant impact on a woman's physical, emotional, and psychological well-being, as it may affect her body image, self-esteem, sexuality, and identity.
- A mastectomy incision is the wound that results from the surgery, which may vary in size, shape, and location depending on the type and extent of the mastectomy. The incision may be closed with stitches, staples, or glue, and covered with a dressing or bandage.
- The first dressing change is usually done within 24 to 48 hours after the surgery, and it involves removing the old dressing, inspecting the incision for any signs of infection or complications, cleaning the wound, applying a new dressing, and educating the client about wound care .
- When the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it, this may indicate that the client is experiencing denial, fear, anger, grief, or depression due to the loss of her breast. These are normal and common reactions that may occur at different stages of the recovery process.
- The best response by the PN to the client's silence is to acknowledge and respect the client's feelings, provide support and reassurance, and offer assistance when needed. This will help to establish trust and rapport with the client, as well as promote her coping and adjustment.
- Therefore, option A is the best answer, as it shows empathy and respect for the client's feelings, while also informing the client that the PN will be available when she is ready to look or talk about the mastectomy. Option A also implies that the PN will not pressure or force the client to do something that she is not comfortable with.
- Options B, C, and D are incorrect answers, as they do not show empathy or respect for the client's feelings, and they may cause more harm than good.

Correct Answer is A
Explanation
This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it. The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.
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