What does the nurse recognize as a risk factor for the development of delirium in older adults?
1. A lack of rigorous exercise that leads to decreased cerebral blood flow
2. Decreased social interaction that leads to profound isolation and psychosis
3. Administration of multiple medications that may cause medication interactions or toxicity
4. Age-related cognitive changes that make older adult patients more susceptible to changes in mental status
Answer: 3
Explanation: Multiple medications may cause medication interactions or toxicity that may result in delirium. While the older adult patient is at higher risk for delirium, delirium is not caused by age-related cognitive changes. A lack of rigorous exercise will not promote delirium. Decreased social interaction can exacerbate delirium, but does not cause the condition.
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A. "Yes, they are actually benign tumors and do not need to be removed." B. "No, these rings are a normal change as people age and do not affect vision." C. "No, these rings may be early indications of glaucoma and should be evaluated by your doctor." D. "Yes, these rings are immature cataracts and will need to be removed when they grow large enough to affect your vision."
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1. The patient's treatment for cancer is effective. 2. The patient's treatment regimen should be more aggressive. 3. The patient has a new cancer site. 4. The patient's cancer is gone.
The UAP reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound the nurse should take which action?
1. Obtain a transparent dressing for the UAP to place on the wound. 2. Request a consult with the wound care nurse. 3. Cleanse the wound and apply a dressing. 4. Tell the UAP to reevaluate the wound in 20 minutes.
The nurse writes the following nursing diagnosis for a client who is not taking his prescribed lithium regularly:
Noncompliance with lithium therapy r/t dislike of side effects as evidenced by subtherapeutic lithium level and client statement that lithium makes his hands shake. Is the nursing diagnosis worded correctly for an actual problem? 1. It expresses an actual client problem, the etiology, and the defining characteristics consistent with the etiology. 2. It expresses a potential client problem and gives defining characteristics. 3. The problem statement is accurate, but the defining characteristics are not con-sistent with the etiology given. 4. Not enough data exist to determine an accurate problem statement.