A client is experiencing the hypoactive type of delirium as evidenced by being lethargic, indifferent, and having trouble focusing on tasks. This client is at risk for which complication?
a. myocardial infarction c. urinary tract infection
b. decubitus ulcers d. constipation
B
In the hypoactive type of delirium the client is observed as merely being lethargic, indifferent, and not asking much of the staff. The client may have trouble focusing on tasks, or simply not paying attention to a person or task. They may be hallucinating without making others aware of it. This type of delirium predisposes the client to decubitus ulcers, aspiration, and pulmonary embolism.
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The laboratory notifies the nursing unit that a substantial amount of test data was mistakenly recorded on the wrong patient's medical record two days ago. Who has the authority to alter the patient's record?
1. Anyone with access to the chart who had time to do so 2. Only administrative staff or the patient's primary physician 3. Only laboratory technicians or nurses who care for the patient 4. No one can correct the error; it is a part of the permanent record.
You are observing a new graduate nurse examine a client's abnormal nipple discharge. Which action by the new graduate would indicate to you that further teaching is needed? The new graduate:
a. assesses the color, consistency, and amount of discharge b. with a sterile cotton tipped swab, obtains a sample of the discharge c. with her bare hands presses on the breast d. prepares the sample for culture and sensitivity
A patient who has recently begun therapy with inhaled dornase alfa for cystic fibrosis asks how the drug works. What is the nurse's best response?
1. "It thins the sputum." 2. "It dilates the bronchioles." 3. "It expands collapsed alveoli." 4. "It prevents mast cell function."
The typical perpetrator in a domestic violence situation is one who:
A. Has a history of being a victim of abuse. B. Has a criminal record. C. Is involved in a new relationship. D. Is on a lower socioeconomic scale.