a nurse is assessing a client with signs of delirium which factor should be the nurses priority in determining the cause

ATI LPN

ATI PN Comprehensive Predictor 2023 Quizlet

1. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?

A. Medication history
B. Fluid and electrolyte imbalances
C. Psychosocial stressors
D. Environmental factors

Correct answer: B

Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.

2. A client who is at 36 weeks of gestation is being taught about nonstress testing. Which of the following statements should the nurse include in the teaching?

A. This test will determine the length of your cervix.
B. You will have your blood pressure taken frequently during the test.
C. You should press the handheld button when you feel your baby move.
D. This test will take about 5 minutes to complete.

Correct answer: C

Rationale: The correct answer is C. In a nonstress test, the client is required to press a handheld button whenever fetal movement is felt, which is then recorded on the monitor. This action helps assess the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. Choices A, B, and D are incorrect because the nonstress test does not involve determining the length of the cervix, monitoring blood pressure, or being completed in 5 minutes. These aspects are not part of the nonstress testing procedure and are unrelated to the purpose of the test.

3. What term refers to the agreement to keep promises?

A. Fidelity
B. Non-maleficence
C. Autonomy
D. Justice

Correct answer: A

Rationale: The term 'fidelity' specifically refers to the agreement to keep promises. Fidelity in healthcare ethics emphasizes the importance of healthcare professionals keeping their commitments to patients. Choice B, 'Non-maleficence,' relates to the ethical principle of doing no harm. Choice C, 'Autonomy,' refers to respecting a patient's right to make decisions about their own healthcare. Choice D, 'Justice,' pertains to fairness and equality in the distribution of healthcare resources.

4. A healthcare professional is reviewing the laboratory report of a client who is receiving filgrastim. Which of the following laboratory values should the healthcare professional monitor to determine the effectiveness of the treatment?

A. WBC count.
B. Serum potassium.
C. Hemoglobin level.
D. Serum creatinine.

Correct answer: A

Rationale: Filgrastim works by stimulating the production of white blood cells. Therefore, monitoring the white blood cell (WBC) count is essential to assess the effectiveness of the treatment. Choice B, serum potassium, is not directly affected by filgrastim therapy. Choice C, hemoglobin level, is important but not the primary indicator of filgrastim's effectiveness. Choice D, serum creatinine, is unrelated to the action of filgrastim and would not reflect its effectiveness.

5. How should a healthcare provider manage a patient with Type 1 diabetes?

A. Administer insulin and monitor blood glucose levels
B. Provide a low-carbohydrate diet and oral hypoglycemics
C. Administer oral hypoglycemics and provide dietary education
D. Provide a high-protein diet and insulin injections

Correct answer: A

Rationale: Type 1 diabetes is managed with insulin administration and regular blood glucose monitoring. Choice A is correct because administering insulin is essential in Type 1 diabetes management to help regulate blood glucose levels. Choices B, C, and D are incorrect because Type 1 diabetes requires insulin therapy as the primary treatment, not oral hypoglycemics or dietary modifications like low-carbohydrate or high-protein diets. Monitoring blood glucose levels is crucial in adjusting insulin doses and ensuring optimal management of the condition.