The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data.
Complete the following sentence by using the list of options.
The nurse should first plan to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale:
• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.
• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.
• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.
• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.
• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.
• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Urinary retention: Urinary retention is a potential side effect of epidural anesthesia due to blockade of sacral nerves, not necessarily a sign of unrelieved pain. It may occur even if pain is well managed, especially with regional anesthetics affecting bladder function.
B. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain. When verbal reporting is limited or unreliable, restlessness may reflect discomfort, agitation, or anxiety related to inadequate pain control following procedures such as epidural administration.
C. Difficulty swallowing: Difficulty swallowing is not associated with pain from a herniated disc or the effects of an epidural. It may instead suggest upper airway or neurologic issues and should prompt assessment for complications unrelated to pain control.
D. Constipation: Constipation is more commonly linked to opioid use or immobility rather than unrelieved pain. While discomfort may contribute, constipation alone does not reliably indicate the adequacy of pain relief in clients receiving an epidural.
Correct Answer is D
Explanation
Rationale:
A. Use touch to convey acceptance: Using touch with clients who are actively hallucinating can be misinterpreted and may provoke fear or aggression. Maintaining a safe physical distance and using verbal reassurance is more appropriate during episodes of hallucination.
B. Avoid attempting to distract the client away from the hallucination: Distraction techniques are often helpful in managing hallucinations. Encouraging the client to engage in a different activity or conversation can help shift their focus away from distressing perceptual disturbances.
C. Encourage group activities: Group settings may increase anxiety or overstimulation for a client who is actively hallucinating. Individualized, low-stimulation environments are more therapeutic during acute symptoms.
D. Provide low lighting in the client's room: A calm, low-stimulation environment including dim lighting can reduce sensory overload and help the client feel more secure. Low lighting may also help minimize misinterpretation of visual stimuli that could feed into hallucinations.
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