which of the following is essential when caring for a client who is experiencing delirium
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor

1. When caring for a client experiencing delirium, which of the following is essential?

Correct answer: B

Rationale: When caring for a client experiencing delirium, it is essential to identify the underlying causative condition or illness. Delirium can be caused by various factors such as infections, medication side effects, dehydration, or underlying health conditions. By identifying the root cause, appropriate treatment can be provided. Controlling behavioral symptoms with low-dose psychotropics (Choice A) may be considered in some cases but is not the primary essential step. Manipulating the environment to increase orientation (Choice C) can help manage symptoms but does not address the underlying cause. Decreasing or discontinuing all previously prescribed medications (Choice D) should only be done under medical supervision, as some medications may be necessary for the client's well-being.

2. What should a healthcare professional assess in a patient presenting with symptoms of a stroke?

Correct answer: A

Rationale: When assessing a patient with suspected stroke symptoms, it is crucial to check for facial drooping as it can be a sign of facial nerve weakness, which is a common indicator of stroke. While monitoring speech difficulties and evaluating arm weakness are also important assessments in stroke cases, they are secondary to facial drooping. Checking for the time of onset of symptoms is essential to determine eligibility for time-sensitive treatments like thrombolytic therapy, but when prioritizing assessments, facial drooping takes precedence.

3. A client with coronary artery disease (CAD) is taking a low-dose aspirin daily. The nurse is reinforcing teaching with the client. The nurse should include that this medication has which of the following therapeutic effects?

Correct answer: B

Rationale: The correct answer is B: Antiplatelet. Aspirin works by inhibiting platelet aggregation, making it an antiplatelet agent. This effect helps reduce the risk of blood clot formation in clients with CAD. Choice A, Analgesic, is incorrect because aspirin's primary action in this context is not pain relief. Choice C, Anticoagulant, is incorrect as aspirin does not directly inhibit coagulation factors. Choice D, Thrombolytic, is incorrect as aspirin does not actively break down clots but rather prevents their formation.

4. A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

Correct answer: B

Rationale: The correct answer is B because the client should press the button when feeling fetal movement to track the baby's activity. Choice A is incorrect because the client should press the button during movements. Choice C is incorrect as the button should be pressed during fetal movements, not contractions. Choice D is irrelevant to the instructions for the nonstress test.

5. A client with an acute myocardial infarction is concerned about extreme fatigue. What is the best strategy to promote independence in self-care?

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with rest periods is the best strategy to promote independence in self-care for a client with acute myocardial infarction. This approach allows the client to regain independence while considering the need for rest to prevent overexertion. Instructing the client to limit all activity until fully rested (Choice A) may hinder independence by promoting inactivity. Assigning assistive personnel to complete self-care tasks (Choice C) does not promote the client's independence. Asking the client's family to assist with self-care (Choice D) may not foster the client's self-reliance and may not always be feasible.

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