Try Naxlex NCLEX-RN (Free-Trial)

The spouse of an older client experiencing delirium is at the client's bedside. The nurse is providing an update to the spouse regarding the client's plan of care. Which of the following responses by the spouse indicates a need for further teaching?

"l brought an updated list of all the medications he takes at home to help you and the doctors determine what the cause of this could be."

"l notified our family members that they should not come visit for a while, until they are better."

"l am not worried. This sort of thing happens all the time to us 'old people.'"

"l am trying to stay positive. I know that most people return to normal, but it is hard to see them like this."

None

Answer and Explanation

The Correct Answer is C

Answer: C. "I am not worried. This sort of thing happens all the time to us 'old people.'"

A. "I brought an updated list of all the medications he takes at home to help you and the doctors determine what the cause of this could be."
This response indicates understanding and proactive involvement in the client’s care. An updated medication list is crucial in evaluating potential causes of delirium, as certain medications or interactions can contribute to changes in mental status.

B. "I notified our family members that they should not come visit for a while, until they are better."
This statement reflects an understanding of the need for a calm environment for the client experiencing delirium. Reducing stimuli and visitors can help the client focus on recovery. It indicates the spouse is aware of the potential impact of social interactions on the client’s condition.

C. "I am not worried. This sort of thing happens all the time to us 'old people.'"
This response indicates a need for further teaching. It reflects a possible misunderstanding of delirium as a normal part of aging, which can be dismissive of the seriousness of the condition. Delirium is often a sign of underlying medical issues and should be treated with concern and urgency. Clients and their families need to understand that delirium is not a typical or benign occurrence and requires appropriate evaluation and intervention.

D. "I am trying to stay positive. I know that most people return to normal, but it is hard to see them like this."
This statement indicates a hopeful attitude while acknowledging the difficulty of the situation. It shows understanding that recovery is possible and reflects the spouse's emotional processing of the situation. Maintaining a positive outlook can be beneficial for both the client and the family during recovery.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Myopia: Myopia refers to nearsightedness, which is caused by refractive errors in the eye and is not associated with Meniere's disease. Myopia results in difficulty seeing distant objects clearly.

B. Vertigo: Vertigo is a hallmark symptom of Meniere's disease and is caused by an excessive accumulation of endolymph fluid in the inner ear. Vertigo presents as a sensation of spinning or dizziness, often accompanied by nausea, vomiting, and imbalance.

C. Photophobia: Photophobia refers to sensitivity to light, which can be associated with various eye conditions but is not a typical manifestation of Meniere's disease. Photophobia may occur in conditions such as migraine headaches or certain eye infections.

D. Presbycusis: Presbycusis refers to age-related hearing loss, which typically occurs gradually over time and is not directly associated with Meniere's disease. Meniere's disease is characterized by sudden episodes of vertigo, hearing loss, tinnitus, and a sensation of fullness or pressure in the ear.

A. "l stopped taking aspirin last week." B. "l did not put my contact lenses in this morning." C. "l took my blood pressure meds with a sip of water." D. "l had a cough and runny nose a couple days ago."

Correct Answer is D

Explanation

A. "I stopped taking aspirin last week.": Stopping aspirin medication prior to surgery is often advised to reduce the risk of bleeding during and after the procedure. The nurse may confirm the timing of discontinuation with the client and verify if any other anticoagulant medications are being taken.

B. "I did not put my contact lenses in this morning.": Removing contact lenses before surgery is a routine precaution to prevent potential corneal abrasions or complications during the procedure. This statement indicates the client is following preoperative instructions.

C. "I took my blood pressure meds with a sip of water.": Taking blood pressure medications with a small amount of water is generally acceptable before surgery. However, the nurse may verify the specific medications the client is taking and their dosing schedule to ensure compliance.

D. "I had a cough and runny nose a couple days ago.": This statement requires further investigation as respiratory symptoms, such as cough and runny nose, may indicate an underlying respiratory infection. Infections can increase the risk of complications during surgery, such as anesthesia-related respiratory issues or postoperative infections. The nurse should assess the severity and duration of the symptoms, inquire about any fever or recent exposure to illnesses, and consider notifying the surgical team for further evaluation and decision-making regarding the client's surgical readiness.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The spouse of an older client experiencing delirium is at the client's bedside. The nurse is providing an update to the spouse regarding the client's plan of care. Which of the following responses by the spouse indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Meniere’s disease. The nurse identifies that which of the following manifestations is caused by an excessive accumulation of endolymph fluid?

Correct Answer is B

Explanation

A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?

Correct Answer is D

Explanation

A nurse is planning care for a client who has suspected cardiac tamponade. Which of the following diagnostic tests should the nurse anticipate the provider to order first?

A nurse is teaching a group of clients about risk factors for developing hypertrophic cardiomyopathy (HCM). Which of the following clients should the nurse understand is most at risk for developing HCM?

A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?

A nurse is explaining the pathophysiology of systemic inflammatory response syndrome (SIRS) to a group of newly licensed nurses. Which of the following statements by the nurse is accurate?

A nurse is caring for a client who has a subarachnoid hemorrhage and asks why they are having a CT angiography. Which of the following should the nurse understand about CT angiography?

A nurse is providing discharge education to a client who has valvular heart disease and peripheral vascular disease. Which of the following should the nurse include in the teaching about valvular heart disease?

A nurse is assessing a client who reports manifestations of tinnitus. Which of the following actions should the nurse perform to determine if movement is causing the clients manifestations to worsen?

A nurse is providing care for a client who has multiple organ dysfunction syndrome (MODS). Which of the following actions is the priority when planning care for this client?