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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Acute alcohol withdrawal occurs when a person who has been dependent on alcohol suddenly stops or significantly reduces intake. This can lead to central nervous system hyperexcitability due to the loss of alcohol’s depressant effects. Symptoms can range from mild tremors and anxiety to severe complications such as delirium tremens, autonomic instability, and seizures. Nursing priorities focus on preventing life-threatening complications and maintaining airway, breathing, and circulation.

Rationale:
A. Seizures are the priority because they represent a life-threatening complication of acute alcohol withdrawal. They occur due to excessive neuronal excitability in the absence of alcohol’s inhibitory effects on the CNS. Seizures can lead to airway compromise, aspiration, injury, and progression to status epilepticus, requiring immediate intervention.

B. Tachycardia is a common autonomic symptom of alcohol withdrawal caused by increased sympathetic nervous system activity. It indicates physiologic stress and requires monitoring, but it is not immediately life-threatening compared to seizures. It is considered a warning sign rather than the highest priority.

C. Elevated temperature may occur in severe withdrawal or delirium tremens due to autonomic instability. However, it is a secondary manifestation and does not pose an immediate threat compared to seizure activity. It should be monitored but is not the priority finding.

D. Cramping is a nonspecific symptom that may occur due to autonomic hyperactivity or gastrointestinal disturbance. Although uncomfortable, it is not life-threatening and does not require urgent intervention compared to neurological complications such as seizures.

A. "Sometimes I am exposed to toxic chemicals at my workplace, but not any that have harmed me." B. "I have switched from tobacco cigarettes to electronic cigarettes" C. "My job and home life are both very stressful, but I haven't been able to do anything about that." D. "Two of my grandparents had diabetes, so I try to eat a healthy diet."

Correct Answer is D

Explanation

Risk-taking behaviors in young adults are influenced by lifestyle choices, environmental exposures, and awareness of health risks. Nurses assess for behaviors that increase long-term disease risk such as poor diet, substance use, unsafe occupational exposure, and unmanaged stress. Limiting risk-taking behavior involves adopting protective health practices that reduce the likelihood of developing chronic illness. Statements indicating preventive health actions reflect effective health promotion and risk reduction.

Rationale:
A. “Sometimes I am exposed to toxic chemicals at my workplace, but not any that have harmed me.” This indicates continued exposure to a potential occupational hazard. Even if no immediate harm is reported, repeated exposure to toxic substances increases long-term risk of respiratory disease, organ damage, or malignancy. This reflects ongoing risk rather than risk reduction.

B. “I have switched from tobacco cigarettes to electronic cigarettes.” This does not indicate true risk reduction because electronic cigarettes still expose the user to nicotine and other harmful chemicals. Vaping is associated with cardiovascular and respiratory risks and does not eliminate addiction or health consequences. This reflects substitution of one risk behavior for another rather than meaningful reduction.

C. “My job and home life are both very stressful, but I haven't been able to do anything about that.” This indicates unmanaged psychosocial stress, which is a known risk factor for cardiovascular disease, anxiety disorders, and poor coping behaviors. Failure to address stress suggests ongoing vulnerability rather than active risk reduction. This statement reflects awareness without implementation of protective strategies.

D. “Two of my grandparents had diabetes, so I try to eat a healthy diet.” This demonstrates appropriate risk reduction behavior by adopting a healthy diet in response to a family history of diabetes. Dietary modification, such as reducing refined sugars and increasing fiber intake, helps lower the risk of developing type 2 diabetes. This reflects proactive health promotion and effective lifestyle adjustment to reduce genetic and environmental risk factors.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

A nurse is monitoring a young adult client for risk-taking behavior. Which of the following statements by the client indicates they are limiting their risk-taking behavior?

Correct Answer is D

Explanation

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