An elderly patient, in the intensive care unit recovering from an abdominal aortic aneurysm repair, begins to show signs of decreased responsiveness
The nurse realizes that which of the following could be the cause of this patient's changing mentation? 1. kinked intravenous infusion line
2. oxygen saturation 96%
3. PCA pump with morphine for pain
4. nothing by mouth status
3
Rationale: Medications are seen as the most prevalent modifiable risk factor for delirium in acute or critically ill elderly patients. Opioid narcotics, such as morphine and fentanyl, are linked to the development of delirium. This is what the nurse should suspect as the cause of the patient's new onset of decreasing responsiveness. The other findings would not negatively affect the patient's mentation.
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A diagnosis of cerebral salt wasting is made for a patient who recently experienced a subarachnoid hemorrhage (SAH) and is hyponatremic
The nurse recognizes the importance of which interventions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Strictly monitoring intake and output 2. Monitoring hypertonic IV fluid therapy 3. Securing a serum sodium level every 6 hours 4. Restricting the patient's fluids to 200 mL daily 5. Administering oral salt supplements
Highlight the first symptoms of dehydration.
a. dizziness or light-headedness b. headache c. tiredness d. all of these
The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning?
1. "Is your pain worse or better than it was an hour ago?" 2. "Do you believe that your nausea is from the new antibiotic?" 3. "What do you think has been causing your current depression?" 4. "What have you done to alleviate the side effects from your medications?"
The single best indicator of fluid status is the nurse's assessment of the client's:
1. Skin turgor 2. Intake and output 3. Serum electrolyte levels 4. Daily weight