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 ["A","C"]

Explanation

A. Monitoring the client's food intake and ensuring a balanced diet: It’s important to monitor food intake to prevent episodes of binge eating and ensure nutritional needs are met. A balanced diet can help stabilize eating patterns and reduce the risk of physical health complications associated with binge eating disorder.

B. Allowing unrestricted access to food: This is not advisable as it may lead to uncontrolled binge eating episodes, exacerbating the disorder.

C. Encouraging the client to engage in regular physical activity: Regular physical activity can help manage weight, improve mental health, and reduce the urge to binge eat. It should be encouraged in a safe and supportive manner.

D. Ignore signs of distress or emotional triggers: Ignoring signs of distress can worsen the disorder. Emotional triggers often lead to binge eating episodes, so addressing these issues is crucial.

E. Minimizing the importance of regular therapy sessions: Therapy is essential for treating the underlying psychological issues associated with binge eating disorder. Minimizing its importance can hinder recovery.

A. Permanent short-term memory loss B. Nasal septum perforation C. Acute pancreatitis D. Respiratory depression/arrest

Correct Answer is D

Explanation

A. Permanent short-term memory loss: While certain substances, particularly chronic alcohol use, can lead to memory impairment, permanent short-term memory loss is not a typical complication of heroin use. Heroin primarily affects the respiratory system and can lead to other health risks such as overdose and infection. Therefore, this choice is incorrect.

B. Nasal septum perforation: Nasal septum perforation is typically associated with the intranasal use of substances like cocaine, which can damage the nasal tissues. Heroin is more commonly injected or smoked, and nasal perforation is not a primary health risk associated with its use. Therefore, this choice is incorrect.

C. Acute pancreatitis: Acute pancreatitis is commonly associated with excessive alcohol consumption rather than heroin use. Heroin primarily affects the central nervous and respiratory systems rather than the pancreas. Therefore, this choice is incorrect.

D. Respiratory depression/arrest: Heroin use poses a significant risk of respiratory depression and arrest, which can be fatal. It depresses the central nervous system and slows down breathing, potentially leading to severe hypoxia and death, especially in the case of overdose. This choice is correct.

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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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