Difficulty: Medium Average Score: 75% Simulated

Passage / Scenario

Nurse's Notes: 0205:
Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified.
Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular.
During data collection, client states, ÔÇ£Can you ask that person to leave my room?ÔÇØ Client is pointing to an empty chair.
0230:
ClientÔÇÖs adult child arrived to the ED and went to clientÔÇÖs room. Client identified family member. Client is pacing and agitated, and states, "I donÔÇÖt understand why I am here.ÔÇØ Adult child asks nurse to talk outside of room and states, ÔÇ£I donÔÇÖt know why they are so confused. They are not normally like this.ÔÇØ Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to room, client voided 250 mL of dark yellow, cloudy urine.
0415:
Client admitted to medical-surgical unit.
Peripheral IV initiated in right arm by RN. Client is agitated, trying to pull out IV, and yelling, ÔÇ£I am leaving now!ÔÇØ
1400:
Client is awake, oriented to person and place, but drowsy. Adult child at bedside. Client is watching television. No hallucinations observed since admission to unit. IV fluids infusing to right arm. Providers Notes: 0230:
Client diagnosis: delirium secondary to a urinary tract infection and dehydration.
0400:
Will transfer client to medical-surgical unit.
Medication Administration Record: 0415:
0.9% sodium chloride IV at 125 mL/hr
Lorazepam 1 mg IV
Sulfamethoxazole/trimethoprim 800/160 mg tab PO
Acetaminophen 325 mg 2 tabs PO

0900:
Lorazepam 1 mg IV
Laboratory Results:
0230:
Serum toxicology screen:
Alcohol: 60 mg/dL (80 to 200 mg intoxication)
Vital Signs:0200:
Temperature 38.6┬░C (101.5┬░F)
Heart rate 104/min
Respiratory rate 18/min
Blood pressure 158/96 mm Hg
Oxygen saturation 98% on room air

0415:
Temperature 38.6┬░C (101.5┬░F)
Heart rate 108/min
Respiratory rate 20/min
Blood pressure 148/94 mm Hg
Oxygen saturation 98% on room air

1400:
Temperature 37.2┬░C (98.9┬░F)
Heart rate 78/min
Respiratory rate 16/min
Blood pressure 128/84 mm Hg

The nurse has reviewed the nursesÔÇÖ notes, medication administration record, and vital signs at 1400.Based on the findings, which of the following client findings indicate an improvement in the clientÔÇÖs condition? (Select all that apply)

The nurse has reviewed the nursesÔÇÖ notes, medication administration record, and vital signs at 1400.Based on the findings, which of the following client findings indicate an improvement in the clientÔÇÖs condition? (Select all that apply)

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