A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

WBC count 13,000/mm

Neuropathy

BUN 16 mg/dL

Hypertension

Answer and Explanation

The Correct Answer is A

A WBC count of 13,000/mm indicates infection, which is a common cause of delirium in older adults. Delirium is an acute confusional state that can result from various factors, such as medications, metabolic disturbances, sensory impairment, or environmental changes. Neuropathy, BUN 16 mg/dL, and hypertension are chronic conditions that do not directly cause delirium, although they may contribute to the client's overall health status.

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Correct Answer is B

Explanation

The correct answer is B. Allow the client unlimited time for the grieving process.

Choice A reason:

Changing the subject when the client becomes upset may prevent the client from expressing their feelings and could hinder their emotional processing. This is not a recommended approach as it may lead to unresolved grief and emotional distress.

Choice B reason:

Allowing the client unlimited time for the grieving process aligns with the principles of palliative care, which focuses on enhancing a patient's quality of life and providing relief from the symptoms and stress of serious illness. It's important to give the client the time and space they need to process their emotions.

Choice C reason:

Discouraging the client from forming new relationships could lead to social isolation and negatively impact their emotional well-being. It's important for the client to have a support system during this difficult time.

Choice D reason:

Offering advice about various treatment choices is not the nurse's role. The nurse should provide information and support, but the decision-making should be patient-centered. It's important to respect the client's autonomy and decisions regarding their care.

A. A client who has stomach pain before presenting a project to his coworkers. B. A client whose partner died 5 years ago still talks about him in the present tense. C. A client who states she will worry about her grades after she finishes planning a party. D. A client who states she did not get a promotion because her boss dislikes her.

Correct Answer is D

Explanation

Rationalization is a defense mechanism that involves making excuses or justifying one's behavior or failures. The client who blames their boss for not getting a promotion is using rationalization to avoid accepting responsibility or acknowledging their shortcomings. The other examples are not related to rationalization, but to other defense mechanisms, such as somatization, denial, and procrastination.

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A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

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