Author Question: When administering a mental status examination to a patient with delirium, the nurse should a. ... (Read 69 times)

MGLQZ · **on:** Jun 25, 2018

When administering a mental status examination to a patient with delirium, the nurse should

a. wait until the patient is well-rested.
b. administer an anxiolytic medication.
c. choose a place without distracting stimuli.
d. reorient the patient during the examination.

Question 2

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago?

a. Provide complete personal hygiene care for the patient.
b. Remind the patient frequently about being in the hospital.
c. Reposition the patient frequently to avoid skin breakdown.
d. Place suction at the bedside to decrease the risk for aspiration.

SeanoH09 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

Answer to Question 2

ANS: B
The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.