A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should then nurse identify as a risk factor for delirium?
Hypersomnia
Amyloid plaque
Urinary tract infection
High cholesterol
The Correct Answer is C
Delirium is a sudden change in mental status characterized by confusion, disorientation, and altered attention. It is often reversible and typically caused by an underlying medical condition rather than a primary psychiatric disorder. Common triggers include infections, metabolic imbalances, medications, and acute illness, especially in older adults. Identifying and treating the underlying cause is essential to resolving delirium.
Rationale:
A. Hypersomnia is not a recognized risk factor for delirium, although sleep disturbances may occur as a symptom once delirium develops. Delirium is more commonly associated with acute physiological stressors rather than isolated sleep pattern changes. Therefore, hypersomnia does not directly contribute to its onset.
B. Amyloid plaque is associated with Alzheimer’s disease, which is a chronic neurodegenerative disorder rather than an acute condition. Although dementia increases vulnerability to delirium, amyloid plaque itself is not an acute risk factor. Delirium develops due to sudden physiological disturbances, not long-term structural brain changes alone.
C. Urinary tract infection is a common precipitating factor for delirium, especially in older adults. Infections trigger systemic inflammatory responses that affect brain function, leading to confusion and altered cognition. Even mild infections can significantly impact mental status in vulnerable clients, making this a key risk factor.
D. High cholesterol is a long-term cardiovascular risk factor but is not directly associated with the development of delirium. It contributes to atherosclerosis over time but does not cause acute changes in brain function. Therefore, it is not considered a risk factor for delirium onset.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A kosher diet follows Jewish dietary laws (kashrut), which regulate the types of foods permitted and how they are prepared. These rules prohibit certain animals, such as pork and shellfish, and require that permissible animals be slaughtered and prepared according to specific guidelines. Fish is allowed only if it has fins and scales. Understanding dietary restrictions is essential for providing culturally competent and appropriate nutritional care in healthcare settings.
Rationale:
A. Clam chowder is not permitted in a kosher diet because clams are shellfish, which are explicitly forbidden under kashrut dietary laws. Any food containing shellfish or derived ingredients from non-kosher seafood is not acceptable. This option does not meet kosher dietary requirements.
B. Pulled-pork sandwich is not allowed because pork is strictly prohibited in kosher dietary practices. Pork is considered non-kosher regardless of preparation method. Clients who observe kosher laws must avoid all pork products and derivatives.
C. Roasted salmon is acceptable in a kosher diet because salmon is a fish that has both fins and scales, meeting kosher requirements. When properly prepared according to dietary laws, it is considered a permissible protein source. It is a suitable menu choice for clients following kosher guidelines.
D. Shrimp salad is not permitted because shrimp are shellfish and do not have fins and scales. Shellfish are classified as non-kosher foods and are prohibited regardless of preparation method. Therefore, this option violates kosher dietary restrictions.
Correct Answer is A
Explanation
Post-anesthesia care unit (PACU) patients require close monitoring after surgery due to residual effects of anesthesia, analgesics, and physiological stress from the procedure. Vital signs are assessed frequently to detect early complications such as respiratory depression, hypothermia, bleeding, or cardiovascular instability. Bradycardia or hypotension after surgery may indicate medication effects or underlying complications that require prompt intervention. The nurse must identify abnormal findings and escalate care when necessary.
Rationale:
A. A heart rate of 52/min is considered bradycardia and should be reported, especially in a post-operative client recently transferred from PACU. This may be caused by residual effects of anesthetic agents, opioid analgesics, or vagal stimulation. It may also indicate early signs of decreased cardiac output and requires prompt evaluation by the provider.
B. A respiratory rate of 16/min is within the normal adult range (12–20 breaths per minute). This indicates adequate respiratory function and does not suggest immediate post-operative respiratory compromise. Therefore, this finding does not require reporting.
C. A temperature of 36.3°C (97.3°F) is slightly on the lower end of normal but is expected in post-anesthesia patients due to effects of anesthesia and intraoperative exposure. Mild hypothermia is common immediately after surgery and typically resolves with warming measures. This finding alone is not concerning.
D. A blood pressure of 116/72 mm Hg is within normal limits and indicates stable hemodynamic status. There is no evidence of hypotension or hypertension requiring intervention. This suggests adequate perfusion and cardiovascular stability after surgery.
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