what is the first step in managing a client with delirium
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ATI LPN

ATI PN Comprehensive Predictor 2023 Quizlet

1. What is the first step in managing a client with delirium?

Correct answer: B

Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.

2. What are the nursing interventions for a patient with a pressure ulcer?

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

3. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D. An HbA1c level less than 7% indicates good long-term glucose control for clients with diabetes. This goal reflects optimal glycemic control and reduces the risk of long-term complications. Choices A, B, and C are incorrect because they do not represent appropriate goals for managing type 1 diabetes in an adolescent. An HbA1c level greater than 8% (choice A) signifies poor glucose control, while a blood glucose level greater than 200 mg/dL at bedtime (choice B) and a blood glucose level less than 60 mg/dL before breakfast (choice C) are not within the target ranges for safe and effective diabetes management.

4. A nurse is reinforcing teaching about using a cane with a client who has left-leg weakness. What instruction should the nurse give?

Correct answer: C

Rationale: The correct instruction for a client with left-leg weakness using a cane is to maintain two points of support on the floor at all times. This technique provides stability and support while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice B is incorrect as advancing the cane and the strong leg together may not provide adequate support and balance. Choice D is incorrect as the distance to advance the cane with each step can vary depending on the individual's needs and abilities.

5. A client with dementia is at risk of falling. What is the best intervention to prevent injury?

Correct answer: B

Rationale: Using a bed exit alarm is the best intervention to prevent injury in a client with dementia at risk of falling. This device alerts staff when the client attempts to leave the bed, allowing for timely assistance and reducing the risk of falls. Placing the client in a room close to the nurses' station may help with supervision but does not provide immediate alerts like a bed exit alarm. Encouraging family members to stay with the client at all times may not be feasible, and raising all four side rails can lead to restraint issues and is not recommended unless necessary for the client's safety.

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