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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Correct Answer is C

Explanation

A. Physical activity level: Physical activity is important for overall health and can have positive effects on mental health by reducing the risk of depression and cognitive decline. However, while it is a significant factor, it is not the most strongly associated factor with mental health in older adults compared to social isolation.

B. Financial status: Financial stability can impact access to healthcare and overall quality of life, but it is not the primary factor influencing mental health. While financial stress can contribute to mental health issues, social factors tend to have a more direct and profound impact.

C. Social isolation: Social isolation is a major risk factor for mental health problems in older adults, including depression, anxiety, and cognitive decline. Lack of social interaction can lead to feelings of loneliness and increase the risk of mental health disorders, making it the most critical factor to consider. This choice is correct.

D. Dietary habits: Good nutrition is essential for maintaining physical and mental health, and poor dietary habits can contribute to various health issues. However, social isolation has a more direct impact on mental health outcomes in older adults compared to diet alone.

A. "I just don't remember what I did this morning." B. "This morning, this morning, this morning..." C. "It was good. The Queen of England visited me there." D. "Snip, snap. Take a nap."

Correct Answer is C

Explanation

A. "I just don't remember what I did this morning." This statement reflects an inability to recall the events of the morning, which is a common symptom in Alzheimer's disease but does not constitute confabulation. It simply indicates memory loss.

B. "This morning, this morning, this morning..." Repetition of words or phrases can indicate a language or communication issue often seen in Alzheimer's disease but is not an example of confabulation. It may reflect confusion or perseverance.

C. "It was good. The Queen of England visited me there." Confabulation involves the creation of false memories or statements to fill in gaps in memory. The client's statement about the Queen of England visiting is a fabricated or distorted memory and is an example of confabulation. This choice is correct.

D. "Snip, snap. Take a nap." This phrase is nonsensical and may indicate disorganized thinking or speech, which can occur in Alzheimer's disease, but it is not an example of confabulation. It does not fill a memory gap with a fabricated story. Therefore, this choice is incorrect.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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