Which are would be a priority of care for a patient who is being admitted to the hospital and its demonstrating signs of delirium?

Safety precaution

Oxygenation

Pain management

Infection

Answer and Explanation

The Correct Answer is A

A.   The priority in managing delirium is ensuring the patient's safety, as delirium increases the risk of falls, self-harm, and other dangerous behaviors. Close monitoring and protective measures are essential.
B.   Oxygenation is important but not the first priority unless the patient shows signs of hypoxia or respiratory distress.
C.   Pain management should be considered, but it is secondary to addressing the safety risks associated with delirium.
D.   Infection should be investigated, but the immediate concern in delirium is safety due to the altered mental state.

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Correct Answer is D

Explanation

A. Dim vision could be a sign of many conditions but is not the first indicator the nurse should assess for neurologic status.

B. Papilledema (swelling of the optic disc) is a late sign of increased intracranial pressure and is not immediately available on assessment.
C. Body temperature is important but not as directly related to the neurological status as LOC.
D. The level of consciousness (LOC) is one of the most important initial indicators of a patient's neurologic status, as it helps assess brain function and the severity of potential neurological injury. A decrease in LOC can indicate significant brain injury or dysfunction.

A. Increased ICP B. Decreased cerebral blood flow (CBF) C. Increased cerebral perfusion pressure (CPP) D. Normal intracranial pressure

Correct Answer is B

Explanation

A. Increased ICP would be a concern when the MAP falls below 70 mm Hg because reduced blood pressure can lead to inadequate cerebral blood flow and worsen ICP.
B. Decreased cerebral blood flow (CBF) is also a concern with low MAP, but the priority is maintaining MAP at a sufficient level to ensure adequate perfusion.
C. Increased CPP is unlikely with a low MAP, as CPP is a product of MAP and ICP.
D. Normal ICP would be a good outcome; however, with a low MAP, the nurse should be concerned about insufficient cerebral perfusion and the risk of increased ICP.

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Which are would be a priority of care for a patient who is being admitted to the hospital and its demonstrating signs of delirium?

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Naxlex Comprehensive Predictor Exams

when assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first?

Correct Answer is D

Explanation

Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

Correct Answer is B

Explanation

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