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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Irritability can be an early sign of increased intracranial pressure (ICP) due to brain dysfunction or pressure on the brainstem.
B. Tachycardia can occur in early shock or in response to pain but is not directly related to increased ICP.
C. Tinnitus (ringing in the ears) is not a primary sign of ICP.
D. Hypotension is typically not associated with increased ICP, which usually causes hypertension.
Correct Answer is A
Explanation
A. Decreasing environmental stimuli can help reduce the risk of seizures and further stress on the patient. This is especially important in cases of meningitis, as the patient may be more sensitive to light, sound, and touch.
B. A vascular assessment is important but not the next immediate action in this scenario.
C. Administering an antipyretic is important but not the priority action right after implementing droplet precautions.
D. Assessing cranial nerves may be necessary later in the assessment but is not the immediate next step.
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