33
A nurse is caring for a group of older adult clients. Which of the following client
findings indicates delirium?
A client wants to know the current time while there is a clock on the wall.
A client asks if family members will be arriving after visiting 1 hr earlier.
A client requests extra blankets when the thermostat in the room indicates 80° F
(25.6° C).
A client expresses dislike of orange juice after reporting earlier that it was a favorite
juice.
Give this one a try later!
client asks if family members will be arriving after visiting 1 hr earlier.
A
Delirium is characterized by a change in cognition that occurs over a short
period of time. It always results from a secondary physiological condition
(e.g., infection, surgery, prolonged hospitalization, hypoxia, fever,
medications) and is a transient disorder. Although delirium can occur with
any age, it is more common in older adults. It frequently progresses in the
evening hours and is sometimes called “sundown syndrome.” Delirium is
characterized by alterations in memory, agitation, restlessness, illusions, or
, hallucinations. A client having no memory of a loved one visiting would be
an indication of delirium and should be closely monitored by the nurse.
172
A nurse is preparing to administer meperidine (Demerol) 75 mg IM to a postpartum
client. Available is meperidine 100 mg/1 mL. How many mL should the nurse
administer? (Round the answer to the nearest tenth.)
Give this one a try later!
0.75
= 0.8
107
A postoperative client is receiving hydromorphone HCL (Dilaudid) via a PCA pump
and reports continuous pain. Which of the following should be the nurse's initial
action?
Administer a bolus of medication.
Check the display on the PCA pump.
Obtain an order for a continuous infusion.
Instruct the client to administer a demand dose.
Give this one a try later!
Check the display on the PCA pump.
The nurse needs to assess the display to determine how much medication
has been administered. Some clients are fearful of developing an addiction
to narcotics and may be reluctant to use the PCA.
,97
An adolescent is undergoing detoxification for chemical abuse. He tells the nurse
that he first “turned to drugs” when his parents wouldn't allow him to get a tattoo.
Which of the following defense mechanisms is the client demonstrating?
Suppression
Somatization
Projection
Dissociation
Give this one a try later!
Projection
rojection is blaming others for unacceptable thoughts and feelings. Rather
P
than accept blame for his choice to abuse drugs, the client projects that
blame onto his parents.
143
A nurse is planning care for a client who has generalized anxiety disorder. Which of
the following interventions is appropriate to promote relaxation?
Assist the client in practicing meditation.
Recognize the client's spiritual preferences.
Encourage the client to identify his positive qualities.
Help the client identify his previous accomplishments.
Give this one a try later!
Assist the client in practicing meditation.
Meditation is an effective technique to promote relaxation and is
recommended for clients who have anxiety disorders.
, 150
A nurse is evaluating a female client who has anorexia nervosa for complications.
Which of the following complications should the nurse expect to find?
Decreased cholesterol levels
Low bone density
Heavy monthly periods
Heat intolerance
Give this one a try later!
Low bone density
The nurse should expect to find low bone density, called osteoporosis, due
to low calcium intake and estrogen deficiency.
3
A nurse is preparing a presentation for coworkers about the various herbal
remedies clients might report using. Which of the following should she include as
an herbal product that might increase sedation in clients receiving antianxiety
medications or analgesics?
Valerian
Feverfew
Milk thistle
Saw palmetto
Give this one a try later!
Valerian
Valerian can potentiate the sedation of antianxiety medications.
A nurse is caring for a group of older adult clients. Which of the following client
findings indicates delirium?
A client wants to know the current time while there is a clock on the wall.
A client asks if family members will be arriving after visiting 1 hr earlier.
A client requests extra blankets when the thermostat in the room indicates 80° F
(25.6° C).
A client expresses dislike of orange juice after reporting earlier that it was a favorite
juice.
Give this one a try later!
client asks if family members will be arriving after visiting 1 hr earlier.
A
Delirium is characterized by a change in cognition that occurs over a short
period of time. It always results from a secondary physiological condition
(e.g., infection, surgery, prolonged hospitalization, hypoxia, fever,
medications) and is a transient disorder. Although delirium can occur with
any age, it is more common in older adults. It frequently progresses in the
evening hours and is sometimes called “sundown syndrome.” Delirium is
characterized by alterations in memory, agitation, restlessness, illusions, or
, hallucinations. A client having no memory of a loved one visiting would be
an indication of delirium and should be closely monitored by the nurse.
172
A nurse is preparing to administer meperidine (Demerol) 75 mg IM to a postpartum
client. Available is meperidine 100 mg/1 mL. How many mL should the nurse
administer? (Round the answer to the nearest tenth.)
Give this one a try later!
0.75
= 0.8
107
A postoperative client is receiving hydromorphone HCL (Dilaudid) via a PCA pump
and reports continuous pain. Which of the following should be the nurse's initial
action?
Administer a bolus of medication.
Check the display on the PCA pump.
Obtain an order for a continuous infusion.
Instruct the client to administer a demand dose.
Give this one a try later!
Check the display on the PCA pump.
The nurse needs to assess the display to determine how much medication
has been administered. Some clients are fearful of developing an addiction
to narcotics and may be reluctant to use the PCA.
,97
An adolescent is undergoing detoxification for chemical abuse. He tells the nurse
that he first “turned to drugs” when his parents wouldn't allow him to get a tattoo.
Which of the following defense mechanisms is the client demonstrating?
Suppression
Somatization
Projection
Dissociation
Give this one a try later!
Projection
rojection is blaming others for unacceptable thoughts and feelings. Rather
P
than accept blame for his choice to abuse drugs, the client projects that
blame onto his parents.
143
A nurse is planning care for a client who has generalized anxiety disorder. Which of
the following interventions is appropriate to promote relaxation?
Assist the client in practicing meditation.
Recognize the client's spiritual preferences.
Encourage the client to identify his positive qualities.
Help the client identify his previous accomplishments.
Give this one a try later!
Assist the client in practicing meditation.
Meditation is an effective technique to promote relaxation and is
recommended for clients who have anxiety disorders.
, 150
A nurse is evaluating a female client who has anorexia nervosa for complications.
Which of the following complications should the nurse expect to find?
Decreased cholesterol levels
Low bone density
Heavy monthly periods
Heat intolerance
Give this one a try later!
Low bone density
The nurse should expect to find low bone density, called osteoporosis, due
to low calcium intake and estrogen deficiency.
3
A nurse is preparing a presentation for coworkers about the various herbal
remedies clients might report using. Which of the following should she include as
an herbal product that might increase sedation in clients receiving antianxiety
medications or analgesics?
Valerian
Feverfew
Milk thistle
Saw palmetto
Give this one a try later!
Valerian
Valerian can potentiate the sedation of antianxiety medications.
