Author Question: An older adult has developed hallucinations. For which of the following should the nurse assess? ... (Read 51 times)

RYAN BANYAN · **on:** Jul 11, 2018

An older adult has developed hallucinations. For which of the following should the nurse assess? (Select all that apply.)

A) Digoxin toxicity
B) Hyperglycemia
C) Infection
D) Myocardial infarction
E) Stroke

Question 2

During an interview with an older adult, the client moves her chair back. Which of the following responses by the nurse is most appropriate?

A) Stop the interview and give her recovery time.
B) Move own chair closer.
C) Sit upright, leaning back.
D) Ask the client if she is okay.

mmj22343 · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

Ans: A, C, E
Infection, digoxin toxicity, and a stroke can all lead to hallucinations. Hyperglycemia and myocardial infarction generally do not.

Answer to Question 2

Ans: C
It is important to consider the physical space required for the person to feel at ease when communicating with others. Men usually like to have larger personal space than women. Sit upright and leaning back will give more personal space. The nurse adjusts to cultural needs of clients, including nonverbals. There is no need to stop the interview or ask if she is okay.