Category: Uncategorized

A nurse is reviewing a physician’s order for a patient with a known, documented allergy to penicillin. The nurse administers an antibiotic that is within the penicillin family, resulting in the patient experiencing anaphylactic shock. This is an example of:

The client in the early stage of Alzheimer’s disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, “I am tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?” The nurse should tell the son:

A nurse is assessing an older adult client who was admitted to the medical unit with pneumonia. The client’s family reports that the client was independent and cognitively intact two days ago. During the evening shift, the nurse observes that the client is disoriented, has difficulty focusing on questions, and alternates between agitation and drowsiness. The nurse suspects the client may be experiencing delirium rather than dementia. Which assessment findings support the nurse’s suspicion of delirium?Select all that apply.

 A nurse assesses a client who reports chronic gastrointestinal discomfort, headaches, and fatigue for several years. Extensive medical testing has revealed no identifiable physiological cause. The client continues to seek evaluations from multiple specialists and expresses intense worry about the symptoms. Which interpretation by the nurse is most appropriate?

Question: The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? 

Question: A patient admitted with DKA secondary to UTI was weaned off an insulin drip 30 minutes ago. Patient feels lightheaded and sweaty. What should the nurse do first? 

The son of a client with Alzheimer’s disease excitedly tells the nurse, “Mom was singing one of her favorite old songs. I think she is getting her memory back!” What response by the nurse is most appropriate?

A nurse uses the CAGE screening tool during an assessment interview. Which client statement corresponds to the “G” component of the CAGE questionnaire?

A hospitalized older adult with sudden confusion attempts to climb out of bed and states, “I need to go to work right now.” The nurse notes the client was oriented earlier in the morning. Which finding most strongly supports delirium rather than dementia?

A nurse is caring for a client with moderate major neurocognitive disorder due to Alzheimer’s disease in a long-term care facility. The client becomes anxious when routines change, occasionally forgets how to complete basic tasks such as dressing, and sometimes becomes frustrated when unable to find words. The nurse is developing interventions to promote safety, reduce confusion, and support functional independence. Which nursing interventions are appropriate for this client?Select all that apply.