The nurse has reviewed the nurses’ notes, provider’s note, and laboratory results at 0230.

Exhibits

For each client’s finding, specify if the finding is consistent with delirium or Alzheimer’s disease. Each finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row.

Sudden onset of confusion

Hallucinations

Agitation

Current medical diagnosis

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}

a. Sudden onset of confusion

Delirium: Yes. Sudden onset of confusion is a common symptom of delirium, which can develop over hours or days.

Alzheimer’s disease: No. Alzheimer’s disease typically involves a gradual decline in memory, thinking, and reasoning skills.

b. Hallucinations

Delirium: Yes. Hallucinations are a symptom of delirium.

Alzheimer’s disease: Yes. While not as common, hallucinations can occur in later stages of Alzheimer’s disease.

c. Agitation

Delirium: Yes. Agitation is a common symptom of delirium.

Alzheimer’s disease: Yes. Agitation can occur in Alzheimer’s disease, particularly in the middle and later stages.

d. Current medical diagnosis

Delirium: Yes. The client’s current diagnosis is delirium secondary to a urinary tract infection and dehydration.

Alzheimer’s disease: No. The client’s current diagnosis does not indicate Alzheimer’s disease.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:
The statement "Assist the client to use new coping strategies" is important but not the first step. Before introducing new coping strategies, it is essential to build a foundation of trust and rapport. This can only be achieved by first establishing confidentiality guidelines.

Choice B reason:
The statement "Help the client to make behavioral changes" is also crucial but not the initial step. Behavioral changes require a trusting relationship and a safe environment, which are established through clear confidentiality guidelines.

Choice C reason:
The statement "Share information with the client about her disorder" is necessary for education and empowerment but should come after establishing trust. The client needs to feel secure that their information will be kept confidential before they can fully engage in learning about their condition.

Choice D reason:
The statement "Establish confidentiality guidelines with the client" is the correct response. Establishing confidentiality is the first step in building a therapeutic nurse-client relationship. It ensures that the client feels safe and secure in sharing personal information, which is essential for effective treatment and care.

A. "These symptoms will improve over time." B. "Continue the medication as prescribed." C. "You should decrease your intake of sodium." D. "You will need to have your blood drawn."

Correct Answer is D

Explanation

Choice A reason:
The statement "These symptoms will improve over time" is not appropriate in this context. Lethargy, muscle weakness, and blurred vision are potential signs of lithium toxicity, which requires immediate attention. Lithium toxicity can occur when lithium levels in the blood become too high, and it is crucial to monitor these levels regularly to prevent serious side effects.

Choice B reason:
The statement "Continue the medication as prescribed" is also not appropriate. Continuing the medication without addressing the symptoms could lead to worsening of the client's condition. Lithium toxicity can cause severe health issues, and it is essential to assess the client's lithium levels to determine if an adjustment in dosage is necessary.

Choice C reason:
The statement "You should decrease your intake of sodium" is incorrect. Sodium intake can affect lithium levels in the blood, but it is not advisable to make sudden changes in sodium intake without medical supervision. A sudden decrease in sodium can lead to higher lithium levels, increasing the risk of toxicity.

Choice D reason:
The statement "You will need to have your blood drawn" is the correct response. Monitoring lithium levels through blood tests is essential to ensure they remain within the therapeutic range (0.6 to 1.2 mEq/L). Blood tests help detect any signs of lithium toxicity and allow for timely adjustments to the medication dosage.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an inpatient mental health facility is reviewing the medical record of a client who has bipolar disorder. When planning to establish a nurse-client relationship with the client, which of the following actions should the nurse plan to take first?

Correct Answer is D

Explanation

A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the client's spiritual needs?

A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication?

A nurse is providing teaching about relapse prevention to a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to administer haloperidol 7 mg lIM to a client who is severely agitated. Available is haloperidol injection 5 mg/mL. How manymL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?

A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?