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 the nurse identify as a risk factor for delirium?

Hypersomnia

High cholesterol

Urinary tract infection

Amyloid plaque

Answer and Explanation

The Correct Answer is C

Choice A reason: Hypersomnia causes excessive sleep, not delirium’s acute confusion. It’s unrelated to the restlessness and disorientation seen in this client’s presentation.

Choice B reason: High cholesterol affects vessels, not acute brain function. It’s a chronic risk, not a trigger for delirium’s sudden cognitive shift here.

Choice C reason: UTIs in older adults often cause delirium via systemic inflammation and toxins. This matches the client’s disorientation and restlessness as a risk.

Choice D reason: Amyloid plaque links to Alzheimer’s, a chronic condition. Delirium is acute; plaque doesn’t explain the sudden onset in this scenario.

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Correct Answer is B

Explanation

Choice A reason: Explaining pros and cons informs but may pressure the client. Supporting autonomy respects their choice, aligning with lung cancer end-of-life preferences better.

Choice B reason: Supporting the client’s DNR decision upholds autonomy and aids communication. In lung cancer, respecting end-of-life wishes is critical, making this the best response.

Choice C reason: Involving a social worker delegates support, not directly honoring the client’s wish. Nurses should first affirm autonomy in such terminal cancer scenarios.

Choice D reason: Suggesting family discussion undermines autonomy, adding burden. The client’s decision in advanced cancer should be respected without implying external validation needs.

A. Stand in front of the client to block them from others in the room. B. Apply restraints according to the facility's standing order. C. Ensure there are enough staff members available for assistance. D. Obtain a PRN prescription for restraints from the provider.

Correct Answer is C

Explanation

Choice A reason: Standing in front risks escalation and injury; de-escalation needs space. Safety protocol prioritizes staff positioning away from a combative client’s reach.

Choice B reason: Standing orders for restraints vary; immediate application skips assessment. Ensuring staff support first allows safer, assessed intervention per guidelines.

Choice C reason: Adequate staff ensures safe de-escalation or restraint if needed. It’s the priority, reducing risk to all in a combative situation effectively.

Choice D reason: PRN restraint orders follow de-escalation attempts; staff availability precedes this. Immediate safety via numbers is critical before seeking prescriptions here.

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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 the nurse identify as a risk factor for delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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