which intervention is key when managing a client with delirium

ATI LPN

ATI PN Comprehensive Predictor 2023 Quizlet

1. What intervention is key when managing a client with delirium?

A. Administer antipsychotic medication to calm the client
B. Identify any reversible causes of delirium
C. Provide a low-stimulation environment
D. Increase environmental stimulation

Correct answer: B

Rationale: The correct intervention when managing a client with delirium is to identify any reversible causes. Delirium can be caused by various factors such as infections, medications, dehydration, or metabolic imbalances. Administering antipsychotic medications (Choice A) may worsen delirium and should be avoided unless necessary for specific indications. Providing a low-stimulation environment (Choice C) is beneficial as it can help reduce agitation and confusion in individuals with delirium. Increasing environmental stimulation (Choice D) is contraindicated as it can exacerbate symptoms in delirious patients. Therefore, the priority should be on identifying and addressing reversible causes to effectively manage delirium.

2. What is the most appropriate response when a client with chronic kidney disease asks about fluid restrictions?

A. Fluid restrictions are not needed for all clients with chronic kidney disease.
B. You may need to limit fluid intake to prevent fluid overload.
C. Fluid restrictions are based on your lab results and daily weights.
D. Restricting fluids is only necessary during dialysis.

Correct answer: B

Rationale: The most appropriate response when a client with chronic kidney disease asks about fluid restrictions is to inform them that limiting fluid intake may be necessary to prevent fluid overload. This is crucial in managing the condition and preventing complications such as edema and electrolyte imbalances. Choice A is incorrect as fluid restrictions are commonly advised for clients with chronic kidney disease. Choice C is partially correct as fluid restrictions are indeed based on lab results and daily weights, but the primary goal is to prevent fluid overload. Choice D is incorrect because fluid restrictions are not limited to just during dialysis; they are often recommended throughout the day to manage the condition.

3. What is an essential nursing intervention for a client experiencing delirium?

A. Control behavioral symptoms with low-dose psychotropics
B. Identify the underlying causative condition
C. Increase environmental stimulation
D. Administer antipsychotic medication

Correct answer: B

Rationale: The correct answer is B - 'Identify the underlying causative condition.' When a client is experiencing delirium, it is crucial to determine the root cause of this acute change in mental status. This can involve a thorough assessment to identify any medical conditions, medications, infections, or environmental factors that may be contributing to the delirium. By pinpointing the underlying cause, appropriate interventions can be implemented to address the specific issue. Choices A, C, and D are incorrect because controlling behavioral symptoms with low-dose psychotropics, increasing environmental stimulation, and administering antipsychotic medication do not target the primary need of identifying and addressing the causative condition of delirium.

4. A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

A. Hemoglobin A1c of 6%
B. Fasting blood glucose of 90 mg/dL
C. Blood glucose of 200 mg/dL
D. Blood glucose of 100 mg/dL

Correct answer: C

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.

5. What are the key differences between viral and bacterial infections?

A. Viral infections typically last longer than bacterial infections.
B. Bacterial infections typically cause high fever.
C. Both bacterial and viral infections cause rashes.
D. Viral infections cause sudden onset of symptoms.

Correct answer: A

Rationale: The correct answer is A. Viral infections typically last longer than bacterial infections. This is because viral infections often require the body's immune system to fight off the virus, leading to a longer duration of illness. Bacterial infections, on the other hand, often cause a rapid onset of symptoms due to the toxins produced by bacteria. Choice B is incorrect because not all bacterial infections cause high fever. Choice C is incorrect because rashes can be caused by both bacterial and viral infections, but not always. Choice D is incorrect because while some viral infections may cause a sudden onset of symptoms, it is not a key distinguishing factor between viral and bacterial infections.