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 C

Explanation

A. Tachycardia is more commonly associated with early stages of shock or compensation but is not a specific sign of increased ICP.
B. Amnesia may occur with a traumatic brain injury, but it is not a direct sign of increased ICP.
C. Restlessness or agitation is an early sign of increased ICP, as the brain becomes more impaired due to pressure, leading to confusion and changes in behavior.
D. Hypotension is not typically associated with increased ICP. In fact, as ICP rises, there may be compensatory mechanisms that maintain blood pressure, and in later stages, the blood pressure may rise.

A. "Use simple, child-like statements when speaking." B. "Incorporate nonverbal cues in the conversation." C. "Use a higher-pitched tone of voice when speaking." D. "Ask multiple choice questions as part of the conversation."

Correct Answer is B

Explanation

A. Using child-like statements may be demeaning and does not support effective communication. It is
important to speak at the client’s level and provide respect.
B. Incorporating nonverbal cues, such as gestures, facial expressions, and pictures, can help facilitate understanding and communication with a person who has aphasia.
C. Using a higher-pitched tone of voice does not aid comprehension and may be perceived as patronizing.
D. Asking multiple-choice questions is helpful, but it is not the most general approach. Using clear, simple language with nonverbal cues is more beneficial.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Correct Answer is C

Explanation

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

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