Correct Answer: C

Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.

Correct Answer: A

Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed to use it as a sleep medication, so encouraging him to wait until bedtime is incorrect. Option C is judgmental and inappropriate as all clients deserve prompt attention. Option D should be used as an adjunct to pain medication, not instead of medication, so instructing him in deep breathing exercises alone is not the priority in this situation.

Correct Answer: B

Rationale: To ensure optimal benefits from a metered-dose inhaler, the client should be instructed to compress the inhaler while slowly breathing in through the mouth. This technique facilitates the medication to reach deep into the lungs, allowing for an optimal bronchodilation effect. Option B is correct as it promotes the proper coordination of inhaler compression and inhalation, ensuring effective drug delivery. Options A, C, and D are incorrect as they do not support deep lung penetration of the medication, which is essential for its effectiveness in treating respiratory conditions.

Correct Answer: D

Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification. Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.

Correct Answer: C

Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.