Difficulty: Medium
Average Score: 78%
Simulated
Passage / Scenario
Nurses' Notes0800: Client is 3 days postoperative.
Currently disoriented to time and place, oriented to self.
Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times.
Client attempts to get out of bed without assistance.
Changes in client's behavior began the prior evening, and the client has been awake most of the night.
Client has refused to eat or drink since the previous day.
Intake and output from the previous day: 250 mL intake, 2,500 mL output.
A call placed to the provider to report findings.
0830: IV fluids initiated by RN. Urine and blood samples collected per the provider's prescription.
The client continues to be restless.
Vital Signs
ÔÇó Heart rate 115/min
ÔÇó Respiratory rate 20/min
ÔÇó BP 90/65 mm Hg
ÔÇó Temperature 38.6┬░C (101.5┬░F)
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
Correct answer
C, D, E, B, E
Rationale
Condition: Delirium due to acute confusion and fever. Actions: Monitor fluid intake/output for dehydration; encourage family presence for reorientation. Parameters: Sleep-wake cycle and fall risk to assess delirium and safety.