what is the primary intervention for a client diagnosed with delirium

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form B

1. What is the primary intervention for a client diagnosed with delirium?

A. Provide a quiet and calm environment to minimize confusion
B. Administer medication to reverse the symptoms of delirium
C. Provide opportunities for social interaction to reduce isolation
D. Encourage the client to remain physically active

Correct answer: A

Rationale: The correct answer is A: Provide a quiet and calm environment to minimize confusion. For clients diagnosed with delirium, creating a tranquil setting can help reduce agitation and disorientation. This intervention aims to decrease stimuli that may exacerbate symptoms. Administering medication (choice B) is not the primary intervention for delirium; it is usually reserved for specific underlying causes. While social interaction (choice C) and physical activity (choice D) are beneficial for overall well-being, they are not the primary interventions for managing delirium.

2. What is the most important nursing intervention for a patient with diarrhea?

A. Encourage the patient to increase fluid intake.
B. Monitor the patient's skin integrity.
C. Check the patient's electrolyte levels.
D. Educate the patient about infection control measures.

Correct answer: B

Rationale: The correct answer is to monitor the patient's skin integrity. This is crucial because diarrhea can lead to skin breakdown due to frequent bowel movements and increased moisture in the perineal area. By monitoring skin integrity, nurses can prevent skin breakdown, infection, and other associated issues. Encouraging fluid intake (Choice A) is important but not the most critical intervention. Checking electrolyte levels (Choice C) is essential but may not be the top priority at the onset. Educating the patient about infection control (Choice D) is important but secondary to preventing skin breakdown in a patient with diarrhea.

3. How should a healthcare professional manage a patient with a chest tube?

A. Ensuring the chest tube is secured properly and functioning
B. Checking for air leaks and ensuring drainage is working
C. Ensuring chest tube drainage is below chest level
D. Ensuring proper documentation of chest tube output

Correct answer: D

Rationale: Proper documentation of chest tube output is crucial in the care of a patient with a chest tube. While ensuring the chest tube is secured and functioning, checking for air leaks, and maintaining drainage below chest level are important aspects of care, documentation of output is essential for monitoring the patient's condition, assessing the effectiveness of treatment, and ensuring appropriate interventions if needed.

4. A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

A. Oral mucosa
B. Conjunctivae
C. Soles of the feet
D. Ear lobes

Correct answer: A

Rationale: Central cyanosis is best assessed by examining the oral mucosa, as it is a more reliable indicator compared to other areas like the conjunctivae, soles of the feet, and ear lobes. The oral mucosa reflects the oxygen saturation levels of the blood more accurately. Conjunctivae and ear lobes may show cyanosis, but they are not as reliable as the oral mucosa. The soles of the feet are not typically used to assess central cyanosis.

5. When administering an IM injection into a client's deltoid muscle, which of the following actions should the nurse take?

A. Use a 21-gauge needle for the injection
B. Inject the medication at a 90-degree angle
C. Inject the medication 12.7 cm (5 in) below the acromion process
D. Inject the medication 2.54 cm (1 in) below the acromion process

Correct answer: B

Rationale: The correct answer is to inject the medication at a 90-degree angle when administering an IM injection into the deltoid muscle. This angle ensures proper delivery of the medication into the muscle tissue. Choice A is incorrect because the gauge of the needle for a deltoid IM injection is usually smaller, around 23-25 gauge. Choices C and D are incorrect as the injection site for the deltoid muscle is approximately 2.54 cm (1 in) below the acromion process, not 12.7 cm (5 in).