SOLVED

Chapter 16 Question 1 A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia? 1. The confusion cleared when the patient was rehydrated. 2. The patient does not recognize her daughter. 3. The patient’s daughter reports that her mother has been becoming increasingly confused over the last 6 months. 4. The patient’s mentation was clear yesterday. 5. The patient does not recognize that she is confused. Question 2 A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority? 1. Encourage the patient to drink at least 240 mL of fluids. 2. Contact the prescriber about an increase in the haloperidol dosage. 3. Place the patient on seizure precautions. 4. Hold the haloperidol dose and collaborate with the prescriber. Question 3 A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state? 1. Testing indicates that the patient has brain function. 2. The patient has clear breath sounds with no indications of pneumonia. 3. The patient cardiac rhythm strip reveals normal sinus rhythm. 4. The patient’s urinary output has remained adequate throughout the coma state. Question 4 A patient is admitted to the intensive care unit accompanied by a family member who says, “He suddenly started acting funny and couldn’t remember where he was.” The nurse would anticipate that first assessment efforts would focus on which condition? 1. Hypovolemic shock 2. Cerebral infection 3. Ischemic stroke 4. Drug overdose Question 5 A patient in the intensive care unit has pulled out his peripheral intravenous line twice and continually picks at his abdominal dressing. How should the nurse describe this behavior? 1. As hyperactive dementia 2. As hyperactive delirium 3. As hypoactive delirium 4. As mixed dementia Question 6 An elderly patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of decreased responsiveness. The nurse realizes that which situation is the most likely cause of this change in mentation? 1. The patient’s intravenous line is infiltrated. 2. The patient has been NPO for an extended period of time. 3. The patient’s oxygen saturation has dropped from 96% to 90%. 4. The patient was started on a PCA pump with morphine. Question 7 From the use of the CAM-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated? 1. Use the prn order for morphine to control the patient’s pain. 2. Use wrist restraints to maintain monitoring devices and lines. 3. Restrict visitors to times when the patient’s mentation is clearest. 4. Reorient the patient to the environment as needed. Question 8 A patient diagnosed with delirium has a history of adverse reaction to haloperidol. Which medication would the nurse anticipate using instead of haloperidol? 1. Phenytoin 2. Risperidone 3. Morphine 4. Amiodarone Question 9 A patient who was in a coma for one week after surgery is unable to tell the nurse where he lives or what he did for a living. The nurse evaluates this condition as suggesting which change resulting from the coma? 1. The patient now has a learning deficit. 2. The patient has instability of emotions. 3. The patient’s cognition is impaired. 4. The patient was near brain death before the coma resolved. Question 10 An elderly patient is admitted to the intensive care unit with acute respiratory injury from aspiration. The nurse monitors this patient very carefully to avoid onset of polyneuropathy because the patient has history of which disorder? 1. Hypertension 2. Type 2 diabetes mellitus 3. Urinary urgency 4. Congestive heart failure