Deck 17: Mentation and Sensory Motor Complications of Acute Illness

Question 1

A patient diagnosed with delirium has a history of adverse reaction to haloperidol.Which medication would the nurse anticipate using instead of haloperidol?

A)Phenytoin
B)Risperidone
C)Morphine
D)Amiodarone

Answer 1

Risperidone

Question 2

A ventilator-dependent patient has been in a coma for several weeks.Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state?

A)Testing indicates that the patient has brain function.
B)The patient has clear breath sounds with no indications of pneumonia.
C)The patient cardiac rhythm strip reveals normal sinus rhythm.
D)The patient's urinary output has remained adequate throughout the coma state.

Answer 2

Testing indicates that the patient has brain function.

Question 3

An older adult patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of delirium.The nurse realizes that which situation is the most likely cause of this change in mentation?

A)The patient's intravenous line is infiltrated.
B)The patient has been NPO (nothing by mouth)for an extended period of time.
C)The patient's oxygen saturation has dropped from 96% to 90%.
D)The patient was started on a patient-controlled analgesia (PCA)pump with morphine.

Answer 3

The patient was started on a patient-controlled analgesia (PCA)pump with morphine.

Question 4

A patient in the intensive care unit has pulled out her peripheral intravenous line twice and continually picks at her abdominal dressing.How should the nurse describe this behavior?

A)As hyperactive dementia
B)As hyperactive delirium
C)As hypoactive delirium
D)As mixed dementia

Question 5

Upon assessment of a patient in the intensive care unit,the nurse suspects critical illness polyneuropathy is developing.Which finding would support this suspicion?

A)The patient exhibits facial grimacing to painful stimuli but does not withdraw from the stimuli.
B)There is bilateral absence of deep tendon reflexes.
C)Laboratory results reveal elevation of creatine kinase level.
D)The patient exhibits diffuse weakness.

Question 6

An initiative for early identification of critical illness myopathy (CIM)has been undertaken by the nurses in the intensive care unit.These nurses would be most watchful of this complication in which patients? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Patients who have type 1 diabetes mellitus
B)Patients with documented presence of renal calculi
C)Patients admitted with the diagnosis of status asthmaticus
D)Patients sedated with neuromuscular blocking agents
E)Patients who have received high-dose corticosteroid therapy

Question 7

A patient is being maintained under neuromuscular blockade-induced paralysis.Analgesia is also being provided.The level of paralysis is being measured by the train-of-four method.The nurse evaluates that the patient's sedation is adequate when which response occurs?

A)The patient moans when medications for analgesia are reduced.
B)The patient withdraws from a series of four applications of cold water into the ear.
C)The patient's thumb twitches twice when an electrical impulse is applied.
D)The patient responds to at least one of four applications of digital pressure over pressure points.

Question 8

From the use of the confusion assessment method (CAM)-ICU assessment tool,a patient is found to have hypoactive delirium.Which nursing intervention is indicated?

A)Use the prn order for morphine to control the patient's pain.
B)Use wrist restraints to maintain monitoring devices and lines.
C)Restrict visitors to times when the patient's mentation is clearest.
D)Reorient the patient to the environment as needed.

Question 9

A patient newly admitted to the intensive care unit reports that she has not been sleeping well at home.The nurse would conduct assessment for which preexisting conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Taking a beta blocker
B)Use of a bronchodilator
C)Snoring
D)Hypothyroidism
E)Alcoholism

Question 10

A patient in the intensive care unit begins exhibiting seizure activity.What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Hold the patient as still as possible to prevent tissue damage.
B)Roll the patient to the side if possible.
C)Place a padded tongue blade in the patient's mouth.
D)Time the seizure from beginning to end.
E)Call the rapid response team.

Question 11

A patient was recently discharged from the hospital following a protracted illness that included mechanical ventilation and treatment for sepsis.At his first postdischarge physician appointment,the patient reports "just not feeling like myself" and being "tired all the time." How would the nurse respond to this report?

A)"You should feel a lot better now that you are out of the hospital."
B)"I am not surprised because you were very sick."
C)"It may take several weeks before you get your strength back."
D)"You have to follow your discharge instructions and take all your medications correctly."

Question 12

The nurse is providing care to a patient receiving a neuromuscular blocking agent.Which nursing intervention is most important specifically due to this medical intervention?

A)Monitor urine output.
B)Provide eye care.
C)Move the patient as little as possible.
D)Provide mouth care.

Question 13

A patient is demonstrating confusion and difficulty focusing.Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)The confusion cleared when the patient was rehydrated.
B)The patient does not recognize her daughter.
C)The patient's daughter reports that her mother has been becoming increasingly confused over the last 6 months.
D)The patient's mentation was clear yesterday.
E)The patient does not recognize that she is confused.

Question 14

A nurse is about to administer flumazenil to a patient who has experienced oversedation from benzodiazepine use.Before administering this drug,the nurse should prepare to manage which patient response?

A)Hypertension
B)Seizure
C)Sudden temperature elevation
D)Bradycardia

Question 15

A patient in the intensive care unit continues to exhibit seizure activity after receiving lorazepam.He currently has an intravenous infusion of dextrose 5% and 0.45 normal saline infusing at a rate of 125 mL/hr.The nurse would anticipate providing which medication?

A)Fosphenytoin
B)Phenytoin and diazepam
C)Haloperidol
D)Additional lorazepam

Question 16

A patient in the critical care unit had a seizure that was determined to be caused by a low blood glucose level.The patient's blood glucose level is currently normal.Which additional intervention should be implemented to prevent future seizure activity in this patient?

A)Administer Valium orally twice each day.
B)Establish a low-dose continuous phenytoin infusion.
C)Increase the frequency of blood glucose assessment.
D)Frequently monitor brain wave activity.

Question 17

A patient with seizure activity is receiving intravenous phenytoin (Dilantin).Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Assess deep tendon reflexes.
B)Closely monitor serum potassium.
C)Monitor injection site frequently.
D)Turn and reposition every hour.
E)Monitor for the development of rash.

Question 18

An older adult patient admitted to the intensive care unit with acute respiratory injury from aspiration is at risk for developing critical illness polyneuropathy (CIP).What information does the nurse provide to this client's family?

A)Prevention of this condition is important because very few persons experience complete recovery.
B)Tight control of blood glucose may help prevent this condition.
C)The major concern with this illness is impairment of the patient's ability to breath.
D)If this condition develops intensive antibiotic therapy will be necessary.

Question 19

A patient in the intensive care unit begins to seize.The nurse would anticipate initial management of this seizure to include which intravenous medication?

A)Fosphenytoin
B)Lorazepam
C)Propofol
D)Diazepam

Question 20

A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg.Which nursing action is priority?

A)Encourage the patient to drink at least 240 mL of fluids.
B)Contact the prescriber about an increase in the haloperidol dosage.
C)Place the patient on seizure precautions.
D)Hold the haloperidol dose and collaborate with the prescriber.