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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.

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Correct Answer is B

Explanation

A. Severe myopia: Severe myopia, or nearsightedness, is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to balance and hearing rather than vision.

B. Vertigo: Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, which is a sensation of spinning or dizziness. Vertigo is a hallmark symptom of Meniere's disease and is often accompanied by nausea, vomiting, and a feeling of fullness or pressure in the affected ear.

C. Anosmia: Anosmia refers to a loss of the sense of smell and is not typically associated with Meniere's disease. Meniere's disease primarily affects the vestibular system (balance) and auditory system (hearing) rather than the sense of smell.

D. Photopsia: Photopsia refers to the perception of flashes of light in the visual field and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is not directly related to visual disturbances.

A. Elevated erythrocyte sedimentation rate (ESR) B. Increased C-reactive protein (CRP) C. Elevated thyroid-stimulating hormone (TSH) D. Increased brain natriuretic peptide (BNP) E. Increased troponin I

Correct Answer is ["A","B","D","E"]

Explanation

A. Elevated erythrocyte sedimentation rate (ESR): Elevated ESR is commonly seen in inflammatory conditions such as pericarditis. ESR measures the rate at which red blood cells settle in a tube of blood over a certain period, and elevated levels indicate inflammation or tissue damage.

B. Increased C-reactive protein (CRP): CRP is an acute-phase reactant produced by the liver in response to inflammation. Elevated CRP levels are indicative of inflammation, making it a useful marker in pericarditis.

C. Elevated thyroid-stimulating hormone (TSH): Elevated TSH levels are not typically associated with pericarditis. TSH is a hormone produced by the pituitary gland that stimulates the thyroid gland to produce thyroid hormones. Elevated TSH levels are seen in conditions such as hypothyroidism.

D. Increased brain natriuretic peptide (BNP): BNP is a hormone produced by the heart in response to increased pressure and volume overload. Pericarditis can lead to increased pressure within the heart, resulting in elevated BNP levels. Therefore, increased BNP levels are anticipated in pericarditis.

E. Increased troponin I: Troponin I is a cardiac biomarker released into the bloodstream when there is damage to cardiac muscle cells. While pericarditis primarily involves inflammation of the pericardium (the sac surrounding the heart), severe cases can lead to myocardial involvement and subsequent release of troponin I. Therefore, increased troponin I levels may be observed in pericarditis, especially if there is myocardial involvement.

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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 assessing a client who has Meniere’s disease. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

A nurse is reviewing laboratory results for a client who has pericarditis. Which of the following blood test results should the nurse anticipate? (Select All that Apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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