when caring for a client diagnosed with delirium what condition should the nurse prioritize investigating
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. When caring for a client diagnosed with delirium, what condition should the nurse prioritize investigating?

Correct answer: D

Rationale: The correct answer is to investigate for signs of infection when caring for a client diagnosed with delirium. Infections can frequently cause or worsen delirium. While investigating medication history, sensory deficits, and cognitive functioning may be important in the overall care of the client, when prioritizing, the nurse should first rule out or address potential infections due to their significant impact on delirium.

2. A nurse is caring for a client who is postoperative following a thyroidectomy. The nurse should monitor for which of the following findings as a sign of hypocalcemia?

Correct answer: B

Rationale: Tingling in the fingers is a classic sign of hypocalcemia. Following a thyroidectomy, hypocalcemia can occur due to damage to the parathyroid glands, which regulate calcium levels in the body. Nausea, numbness in the toes, and sweating are not specific signs of hypocalcemia. Numbness and tingling usually start in the hands and feet due to their increased nerve sensitivity to low calcium levels.

3. A nurse is reviewing the plan of care for a client who is receiving oxygen therapy. Which of the following interventions should the nurse include to prevent complications?

Correct answer: B

Rationale: The correct answer is B: Provide humidified oxygen. Providing humidified oxygen helps prevent dryness and irritation of the respiratory tract during oxygen therapy. This intervention is crucial in preventing complications such as mucous membrane dryness and potential damage to the airways. Checking the client's oxygen saturation every 2 hours (choice A) is essential for monitoring the client's response to therapy but does not directly prevent complications. Instructing the client to perform deep breathing exercises (choice C) is beneficial for respiratory function but does not directly address preventing complications related to oxygen therapy. Using an oxygen mask for delivery (choice D) is a common method of administering oxygen but does not specifically focus on preventing complications like dryness and irritation.

4. What is the best dietary recommendation for a patient with chronic kidney disease?

Correct answer: A

Rationale: The correct answer is a low-protein diet for a patient with chronic kidney disease. In chronic kidney disease, the kidneys may have difficulty filtering waste products from protein metabolism, leading to a buildup of toxins in the body. Therefore, reducing protein intake can help lessen the workload on the kidneys. Choices B, C, and D are incorrect. A high-protein diet would increase the workload on the kidneys, while a low-sodium diet is beneficial for conditions like hypertension or heart failure but not specifically targeted for chronic kidney disease. A high-sodium diet can worsen fluid retention and hypertension in patients with kidney disease.

5. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

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