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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Echolalia: Echolalia, the repetition of words or phrases spoken by others, is a common characteristic of autism spectrum disorder. It can be part of the individual’s attempt to communicate or self-stimulate and may be indicative of difficulties in expressive language development.
B. Ambivalence: Ambivalence, the state of having mixed feelings or contradictory ideas about something or someone, is more commonly associated with conditions like schizophrenia, not ASD.
C. Expressive affect: Individuals with ASD often have difficulties with expressive affect, meaning they may show limited emotional expression, which contrasts with the term "expressive affect" suggesting full emotional expression.
D. Associative looseness: Associative looseness, a symptom where a person’s thoughts are disconnected and fragmented, is more characteristic of schizophrenia than ASD.
Correct Answer is B
Explanation
A. Narcissistic personality disorder: Individuals with narcissistic personality disorder may display arrogance and entitlement but are not typically prone to aggression in this context.
B. Antisocial personality disorder: Aggressive and impulsive behavior, often involving disregard for others' rights and legal norms, is characteristic of antisocial personality disorder.
C. Borderline personality disorder: Borderline personality disorder is associated with emotional instability, impulsivity, and difficulties in relationships, but aggression in a bar setting is more suggestive of antisocial behavior.
D. Histrionic personality disorder: This disorder involves attention-seeking behavior and emotional expression, which is different from the aggressive and antisocial behavior described.
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