What is an essential nursing intervention for a client experiencing delirium?

Correct Answer: B

Rationale: The correct answer is B - 'Identify the underlying causative condition.' When a client is experiencing delirium, it is crucial to determine the root cause of this acute change in mental status. This can involve a thorough assessment to identify any medical conditions, medications, infections, or environmental factors that may be contributing to the delirium. By pinpointing the underlying cause, appropriate interventions can be implemented to address the specific issue. Choices A, C, and D are incorrect because controlling behavioral symptoms with low-dose psychotropics, increasing environmental stimulation, and administering antipsychotic medication do not target the primary need of identifying and addressing the causative condition of delirium.

Correct Answer: D

Rationale: The nurse should prioritize performing a wound culture before administering antibiotics to ensure appropriate treatment. This step helps identify the specific infecting organism and its susceptibility to different antibiotics, guiding effective antibiotic therapy. Changing the dressing daily (Choice A) is important but comes after assessing the infection and initiating appropriate treatment. Cleansing the wound with an antiseptic solution (Choice B) and applying a wet-to-dry dressing (Choice C) are interventions that may be necessary but are secondary to determining the most suitable antibiotic therapy based on the wound culture results.

Correct Answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial when managing a client with a wound infection. This step helps identify the specific pathogens causing the infection, allowing for the prescription of the most effective antibiotics. Changing the wound dressing every 24 hours (Choice A) is important for wound care but not the priority when an infection is present. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and may delay wound healing. Applying a wet-to-dry dressing (Choice D) is not recommended for infected wounds as it can cause trauma to the wound bed during dressing changes.

Correct Answer: B

Rationale: The correct lifestyle change that should be emphasized for a client with hypertension is to reduce caffeine and sodium intake. Caffeine can temporarily raise blood pressure, and high sodium intake is linked to increased blood pressure levels. Therefore, reducing these two components can help manage blood pressure in individuals with hypertension. Choices A, C, and D are incorrect because increasing intake of dairy products, consuming carbohydrate-rich meals, and limiting intake of leafy green vegetables do not specifically address the factors that contribute to high blood pressure in hypertension.

Correct Answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial for determining the specific type of infection present and selecting the most effective antibiotic treatment. Changing the dressing daily (Choice A) is a routine wound care practice but may not address the root cause of the infection. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and delay wound healing. Applying a wet-to-dry dressing (Choice D) is an outdated practice that can cause trauma to the wound bed and hinder the healing process.