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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Trauma-informed care is a form of therapy that encourages the avoidance of discussing past traumatic events: This statement is incorrect. Trauma-informed care does not avoid discussing trauma but rather approaches it in a sensitive and supportive manner.
B. Trauma-informed care focuses solely on treating physical injuries caused by traumatic events: Trauma-informed care encompasses much more than physical treatment. It addresses the psychological, emotional, and social impact of trauma.
C. Trauma-informed care is a framework that emphasizes understanding the impact of trauma and how to provide sensitive and supportive care: This is correct. Trauma-informed care involves recognizing the prevalence and impact of trauma, understanding trauma symptoms and reactions, and providing care that avoids re-traumatization and promotes healing.
D. Trauma-informed care is a treatment approach that aims to erase traumatic memories from an individual's mind: This is incorrect. Trauma-informed care does not aim to erase memories but rather to support individuals in processing and coping with traumatic experiences.
Correct Answer is D
Explanation
A. Early-stage dementia: At this stage, individuals might have some memory problems but can generally maintain independence. The symptoms described (significant memory loss, confusion, difficulty with language, and struggles with daily tasks) are more advanced than what is typically seen in early-stage dementia.
B. Mild cognitive impairment: This is a transitional stage between normal cognitive aging and dementia. It involves some memory problems and cognitive changes but not severe enough to impact daily functioning to the extent described.
C. Severe dementia: In this stage, individuals typically require assistance with most activities of daily living, have severe memory loss, and may not recognize close family members or understand their surroundings. The described symptoms do not yet indicate this level of severity.
D. Moderate dementia: This stage is characterized by more pronounced memory loss, confusion, difficulty with language, and an increasing need for help with daily tasks such as dressing and bathing, matching the client's symptoms.
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