Which assessment demonstrates the nurse's understanding of the relationship between substance abuse and the development of symptoms characteristic of delirium?
a. Determining the patient's age and gender
b. Evaluating the patient's food and fluid intake over the last 48 hours
c. Observing the patient for fine tremors of the hands, especially the fingers
d. Determining the amount of caffeine the patient ingested in the last 24 hours
ANS: D
Some people who ingest large amounts of caffeine develop delirium. The remaining options are not relevant to caffeine ingestion or the abuse of any other substance.
You might also like to view...
The nurse counsels a family not to shield their 6-year-old child from the death of his grandfather because children who are protected from the pain of bereavement frequently develop feelings of (select all that apply):
1. fear. 2. anger. 3. abandonment. 4. blame. 5. inability to express feelings.
The client who has experienced blunt trauma to the chest is at risk for developing a hemo-thorax. Which would the nurse expect to find in a client with a hemothorax?
A. Hemoptysis B. Paradoxical chest movements C. Percussion dullness on affected side D. Hypertympanic sound on affected side
To palpate the inguinal nodes, you should have the patient:
a. bend over a table and cough. b. lie supine with knees slightly flexed. c. lie supine with legs extended. d. stand and cough vigorously.
The nurse assessing a child with cellulitis will most often find which of the following classic symptoms?
a. skin breakdown and areas of ulceration resulting from inflammation of cells b. complaint of burning and tightness in the area of the cellulitis c. erythema, swelling, warmth, pain, and diffuse borders of the infected area d. no visible signs but the child will complain of varying types of pain