You are monitoring the vital signs of an 74yrold man who was admitted for a head injury after he tripped and fell at home. He takes anticoagulants for atrial fibrillation. On arrival his vital signs were stable at BP 150/86, pulse 84, respirations 14/min, but his family reported that he was more restless than usual. He lives alone after his wife passed away. 2 hours after admission, his vital
signs are now BP 166/74, pulse 54, respirations 11/min. He is now quiet and appears sleepy. He is on 2L nasal cannula and has been placed on neutropenic precautions.
The Correct Answer is ["He is now quiet and appears sleepy."]
He is now quiet and appears sleepy. This is correct because it indicates a change in the level of consciousness, which could be a sign of increased intracranial pressure or bleeding in the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
No explanation
Correct Answer is D
Explanation
A. Incorrect. Complete darkness at night can increase confusion and agitation in clients with Alzheimer's disease. The room should have adequate lighting and a night light to help orient the client and prevent falls.
B. Incorrect. Suction equipment is not necessary for clients with Alzheimer's disease unless they have respiratory problems or difficulty swallowing. Suction equipment can be noisy and frightening for clients with cognitive impairment and should be avoided unless indicated.
C. Incorrect. A walker or cane may be helpful for clients with Alzheimer's disease who have mobility issues, but it is not an essential item to include in the room. A walker or cane can also pose a tripping hazard or be used as a weapon by agitated clients.
D. Correct. Clocks, calendar, family photos are appropriate items to include in the room of a client with Alzheimer's disease. They can help the client maintain orientation to time, place, and person, and provide comfort and familiarity.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.