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. A client is receiving IV fluids and has developed phlebitis. What is the next step the nurse should take?

A. Monitor the site for further swelling
B. Remove the catheter and place it in another site
C. Reduce the flow rate of IV fluids
D. Switch to oral hydration

Correct answer: B

Rationale: The correct next step when a client develops phlebitis while receiving IV fluids is to remove the catheter and place it in another site. Phlebitis is inflammation of a vein, and leaving the catheter in the same site can lead to further complications. Monitoring the site for further swelling, as in choice A, is not enough as the source of inflammation needs to be removed. Choice C, reducing the flow rate, may not address the underlying issue causing phlebitis. Switching to oral hydration, as in choice D, is not necessary for addressing phlebitis related to IV fluid administration.

3. A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

A. Do not press the button during baby's movements
B. You should depress the button when you feel your baby move
C. Press the button only during contractions
D. Do not eat before the test

Correct answer: B

Rationale: The correct answer is B because the client should press the button when feeling fetal movement to track the baby's activity. Choice A is incorrect because the client should press the button during movements. Choice C is incorrect as the button should be pressed during fetal movements, not contractions. Choice D is irrelevant to the instructions for the nonstress test.

4. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

A. Family members who smoke should be at least 10 ft away from the client when oxygen is in use
B. Nail polish should not be used near a client who is receiving oxygen
C. A 'No Smoking' sign should be placed on the front door
D. Cotton bedding and clothing should be replaced with items made from wool

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

5. What is a primary symptom of left-sided heart failure?

A. Shortness of breath
B. Edema
C. Rapid heartbeat
D. Confusion

Correct answer: A

Rationale: Shortness of breath is a primary symptom of left-sided heart failure. In this condition, the heart's inability to pump effectively leads to fluid backing up into the lungs, causing difficulty breathing. Edema (swelling), rapid heartbeat, and confusion are more commonly associated with other conditions or right-sided heart failure. Edema is often seen in right-sided heart failure due to fluid accumulation in the body, rapid heartbeat can be a general sign of heart issues, and confusion is more related to decreased brain perfusion in severe heart failure cases.