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Free NCLEX-RN Exam Braindumps (page: 157)

Page 157 of 431
PDF with 862 Questions

A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?

  1. The delirious client is capable of returning to his previous level of functioning.
  2. The delirious client is incapable of returning to his previous level of functioning.
  3. Delirium entails progressive intellectual and behavioral deterioration.
  4. Delirium is an insidious process.

Answer(s): A

Explanation:

(A) This answer is correct. If the cause is removed, the delirious client will recover completely. (B) This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. (C) This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. (D) This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.



A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?

  1. The delirious client is capable of returning to his previous level of functioning.
  2. The delirious client is incapable of returning to his previous level of functioning.
  3. Delirium entails progressive intellectual and behavioral deterioration.
  4. Delirium is an insidious process.

Answer(s): A

Explanation:

(A) This answer is correct. If the cause is removed, the delirious client will recover completely. (B) This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. (C) This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. (D) This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.



A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:

  1. Aplastic crisis
  2. Vaso-occlusive crisis
  3. Dactylitis crisis
  4. Sequestration crisis

Answer(s): D

Explanation:

(A) Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5­10 days. (B) Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. (C) Dactylitis crisis, or "hand-foot syndrome," causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. (D) Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.



A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:

  1. Aplastic crisis
  2. Vaso-occlusive crisis
  3. Dactylitis crisis
  4. Sequestration crisis

Answer(s): D

Explanation:

(A) Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5­10 days. (B) Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. (C) Dactylitis crisis, or "hand-foot syndrome," causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. (D) Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.



Page 157 of 431



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Naveen Ahlam commented on November 29, 2024
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