The nurse is caring for an older adult client who is experiencing delirium. Which of the following should be the priority action by the nurse?

Administer diazepam.

Obtain a medical history.

Start intravenous fluids.

Raise 3 of the 4 side rails of the bed.

Answer and Explanation

The Correct Answer is B

A. Administer diazepam: This is not a first-line treatment for delirium and could exacerbate confusion or sedation, potentially worsening delirium.

B. Obtain a medical history: Delirium is often caused by underlying medical conditions such as infections, electrolyte imbalances, or medication side effects. Obtaining a medical history is crucial for identifying and treating the underlying cause, making it the priority action.

C. Start intravenous fluids: While IV fluids might be necessary in cases of dehydration or electrolyte imbalances, identifying the underlying cause of delirium through medical history is more urgent.

D. Raise 3 of the 4 side rails of the bed: This action may help prevent falls but does not address the underlying cause of delirium. Moreover, the use of side rails can sometimes increase the risk of injury or entrapment.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

A. Chronic pain: Depression can manifest as physical symptoms, including chronic pain, in adolescents.

B. Low self-esteem: This is a common feature of depression, where individuals may feel worthless or inadequate.

C. Euphoria: Euphoria is more associated with manic episodes, not depression.

D. Irritability: Depression in adolescents often presents with irritability rather than sadness.

E. Insomnia: Sleep disturbances, including insomnia, are common symptoms of depression.

A. Clozapine (Clozaril) B. Galantamine (Razadyne) C. C Olanzapine (Zyprexa) D. Sertraline (Zoloft)

Correct Answer is B

Explanation

A. Clozapine (Clozaril): Clozapine is an antipsychotic used primarily for schizophrenia, not for cognitive improvement in Alzheimer's disease. It is not indicated for treating Alzheimer’s disease.

B. Galantamine (Razadyne): Galantamine is an acetylcholinesterase inhibitor used to improve cognitive function in patients with mild to moderate Alzheimer's disease. It works by increasing the levels of acetylcholine in the brain, which helps with memory and cognitive processes.

C. Olanzapine (Zyprexa): Olanzapine is an antipsychotic used to treat schizophrenia and bipolar disorder. It is not used for cognitive enhancement in Alzheimer's disease and may actually worsen cognitive function in some cases.

D. Sertraline (Zoloft): Sertraline is an antidepressant used primarily for depression and anxiety disorders. It is not indicated for the cognitive symptoms of Alzheimer's disease.

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The nurse is caring for an older adult client who is experiencing delirium. Which of the following should be the priority action by the nurse?

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