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.
 - 
	
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
The practical nurse (PN) should observe minimal time, maximum distance, and protective shielding when administering direct care to a client who has four gold seed implants on a chest wall tumor.
Minimal time refers to limiting the duration of direct exposure to the client with the gold seed implants. This helps minimize the nurse's exposure to radiation.
Maximum distance refers to maintaining a safe distance from the client with the gold seed implants. The nurse should try to stay as far away as possible while still being able to provide necessary care.
Protective shielding involves using lead aprons, gloves, and other appropriate shielding materials to protect oneself from radiation exposure. These protective measures help reduce the nurse's exposure to radiation during care activities.
B. Rotating assignments with other staff during the shift may not be necessary in this situation unless there are specific staffing requirements or guidelines in place. The primary focus should be on minimizing the nurse's exposure to radiation through time, distance, and shielding.
C. Virtual observation and wearing a film badge for exposure are not applicable in this context. These measures are more relevant for monitoring radiation exposure over time and do not directly address the precautions needed during direct care.
D. Standard precautions with negative pressure isolation are not specifically indicated for a client with gold seed implants. Negative pressure isolation is typically used for clients with infectious diseases that require airborne precautions, and it is not directly related to radiation precautions.
Correct Answer is ["A","C","D"]
Explanation
A. "I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." This statement demonstrates an understanding that certain characteristics of seizures, such as prolonged duration or multiple seizures in succession, may require medical attention and evaluation.
C. "I may never know why I started having seizures." This statement acknowledges the possibility that the underlying cause of the seizures may remain unknown. Seizure etiology can vary, and in some cases, the specific cause cannot be determined despite diagnostic tests.
D. "Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not." This statement recognizes the potential benefits of wearing a medic alert bracelet, which can provide crucial information about the client's condition in case of emergencies. It emphasizes the client's autonomy in making the decision, showing an understanding of the role and significance of the bracelet.
The following statement does not indicate understanding:
"There are really no lifestyle changes that I can do that will affect my risk of having another seizure." This statement is incorrect, as there are lifestyle modifications that can help reduce the risk of seizures, such as getting enough sleep, managing stress, avoiding triggers (if known), and taking prescribed medications as directed.
Regarding the statement "I can stop taking the phenytoin if I go for a while and don't have a seizure," it is not included in the given options.
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