Question

In ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?

Answer 1

Correct Answers:

Identify the underlying cause

Rationale :

◈ Delirium is an acute cognitive disturbance usually caused by an underlying medical condition such as infection, fluid imbalance, or drug toxicity.

◈ The first priority in managing delirium is identifying and correcting the causative factor to reverse the mental status changes.

◈ While supportive interventions like reorientation and calm communication are helpful, they are not effective unless the cause is addressed.

◈ Early treatment of the root cause prevents complications and accelerates recovery.

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Answer 2

Correct Answers:

complex partial

Rationale :

♦️ Complex partial seizures often arise from the temporal lobe and involve automatisms such as lip-smacking or tongue thrusting, as well as impaired awareness.

♦️ The unilateral facial twitching and decreased consciousness described match this seizure type.

♦️ These seizures may begin with a focal onset and evolve to involve altered behavior or confusion afterward.

♦️ Recognition of the seizure type helps guide appropriate antiepileptic therapy and further neurological evaluation.

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Answer 3

Correct Answers:

Difficulty speaking

Rationale :

✔️ Speech difficulties following a hemorrhagic stroke signal potential worsening of the neurologic condition and should be prioritized for immediate reporting.

✔️ Sudden changes in communication abilities may indicate increased intracranial pressure or expanding bleeding.

✔️ Monitoring for these neurologic signs allows timely intervention to prevent further cerebral damage.

✔️ Refusing medication or minor glucose variations are less urgent than acute neurologic decline.

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Answer 4

Correct Answers:

Reduce edema of the brain

Rationale :

🔷 Mannitol is an osmotic diuretic that reduces intracranial pressure (ICP) by drawing water out of brain tissue and into circulation.

🔷 This effect decreases cerebral edema, thereby reducing pressure on brain structures.

🔷 It is especially used in clients with head trauma, brain tumors, or increased ICP to prevent herniation.

🔷 Monitoring serum osmolality and electrolytes is crucial during administration to avoid dehydration or imbalances.

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Answer 5

Correct Answers:

Subacute subdural hematoma

Rationale :

🔶 A subacute subdural hematoma typically presents days to weeks after head trauma, especially in elderly patients.

🔶 The client’s gradual mental decline and history of falling 2 weeks prior without evaluation support this diagnosis.

🔶 Brain atrophy in older adults causes veins to stretch, making them more prone to delayed bleeding.

🔶 Prompt neuroimaging is needed to confirm diagnosis and determine the need for surgical intervention.

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Answer 6

Correct Answers:

A 75 year old female client with osteoporosis and who is on clopidogrel (Plavix) for atrial fibrillation.

Rationale :

✍️ Older adults are at increased risk for traumatic brain injury (TBI) due to falls, which are more common with conditions like osteoporosis and anticoagulant use.

✍️ The use of clopidogrel, an antiplatelet, further increases bleeding risk in case of trauma.

✍️ Atrial fibrillation adds stroke risk, and even a minor fall can result in subdural or intracranial hemorrhage.

✍️ Safety education and fall prevention are critical for this population.

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Answer 7

Correct Answers:

Have the client stand with eyes his closed and touch his nose.

Rationale :

👉 This test evaluates cranial nerve II (optic nerve) by indirectly assessing visual field and balance coordination.

👉 Standing with eyes closed and performing movement requires visual input, and absence of it will challenge the patient’s proprioception and visual guidance.

👉 Visual-spatial orientation is necessary for coordination, and inability may suggest dysfunction of the optic or cerebellar systems.

👉 It's part of a Romberg-type maneuver assessing sensory input and visual integration.

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Answer 8

Correct Answers:

lethargy after administration of pain medication

Rationale :

✳️ Early signs of increased intracranial pressure (ICP) include subtle changes in consciousness, such as lethargy.

✳️ When sedation cannot fully explain the level of drowsiness, it should raise concern for ICP.

✳️ The brain’s sensitivity to pressure makes even minor increases dangerous if unrecognized.

✳️ Continuous neuro monitoring is critical in clients with brain tumors or potential space-occupying lesions.

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Answer 9

Correct Answers:

Allow the drainage to drip onto a sterile gauze pad.

Rationale :

✔️ Clear nasal drainage after head trauma may indicate cerebrospinal fluid (CSF) leak, a serious complication of basilar skull fracture.

✔️ Allowing it to collect on gauze without contamination allows testing for glucose or "halo sign", which confirms CSF.

✔️ Inserting anything into the nares or suctioning increases risk of infection or worsens the injury.

✔️ CSF leakage requires close monitoring for meningitis and intracranial complications.

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Answer 10

Correct Answers:

Immunomodulators are used to prevent relapses.

Rationale :

➡️ In multiple sclerosis (MS), immunomodulatory therapy (e.g., interferons, glatiramer) helps reduce the frequency of relapses and slow disease progression.

➡️ These drugs modify immune response to prevent demyelination rather than treat acute symptoms.

➡️ Corticosteroids are typically reserved for managing acute exacerbations.

➡️ Education should focus on adherence and side effect monitoring, especially flu-like symptoms or depression.

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QLexNursing

1 :
In ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?

2 :
A client is observed with unilateral twitching of facial muscles and repetitive tongue thrusting, with a decrease in level of consciousness. When the nurse reports her findings to the physician, what type of seizure will she indicate she observed?

3 :
A student nurse is caring for a client with acute hemorrhagic stroke who was admitted 1 day ago. Which is the priority assessment finding for the student to report to the primary nurse?

4 :
A nurse is preparing to administer intravenous mannitol, an osmotic diuretic, to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

5 :
An 84-year-old client is brought to the emergency department with reports that his mental status has slowly been declining. He fell 2 weeks ago but did not seek medical attention. Based on this information, what does the nurse suspect the client's diagnosis will be?

6 :
Which of the following clients is most at risk for traumatic brain injury?

7 :
A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?

8 :
The nurse caring for a client with a brain tumor will monitor for which of the following early signs of increased intracranial pressure?

10 :
A client newly diagnosed with multiple sclerosis is receiving education about newly prescribed medications from the nurse. Which of the following will be included in the client teaching?

QLexNursing

1 : In ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?

2 : A client is observed with unilateral twitching of facial muscles and repetitive tongue thrusting, with a decrease in level of consciousness. When the nurse reports her findings to the physician, what type of seizure will she indicate she observed?

3 : A student nurse is caring for a client with acute hemorrhagic stroke who was admitted 1 day ago. Which is the priority assessment finding for the student to report to the primary nurse?

4 : A nurse is preparing to administer intravenous mannitol, an osmotic diuretic, to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

5 : An 84-year-old client is brought to the emergency department with reports that his mental status has slowly been declining. He fell 2 weeks ago but did not seek medical attention. Based on this information, what does the nurse suspect the client's diagnosis will be?

6 : Which of the following clients is most at risk for traumatic brain injury?

7 : A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?

8 : The nurse caring for a client with a brain tumor will monitor for which of the following early signs of increased intracranial pressure?

10 : A client newly diagnosed with multiple sclerosis is receiving education about newly prescribed medications from the nurse. Which of the following will be included in the client teaching?

1 :
In ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?

2 :
A client is observed with unilateral twitching of facial muscles and repetitive tongue thrusting, with a decrease in level of consciousness. When the nurse reports her findings to the physician, what type of seizure will she indicate she observed?

3 :
A student nurse is caring for a client with acute hemorrhagic stroke who was admitted 1 day ago. Which is the priority assessment finding for the student to report to the primary nurse?

4 :
A nurse is preparing to administer intravenous mannitol, an osmotic diuretic, to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

5 :
An 84-year-old client is brought to the emergency department with reports that his mental status has slowly been declining. He fell 2 weeks ago but did not seek medical attention. Based on this information, what does the nurse suspect the client's diagnosis will be?

6 :
Which of the following clients is most at risk for traumatic brain injury?

7 :
A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?

8 :
The nurse caring for a client with a brain tumor will monitor for which of the following early signs of increased intracranial pressure?

10 :
A client newly diagnosed with multiple sclerosis is receiving education about newly prescribed medications from the nurse. Which of the following will be included in the client teaching?