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. Medication B. Dosage C. Route D. Time

Correct Answer is C

Explanation

Choice A reason: Erythromycin is specified, so the medication is clear. No ambiguity exists here for clarification. Scientifically, drug identity is explicit, and errors arise elsewhere, making this unnecessary to question unless a different antibiotic was intended, which isn’t suggested.

Choice B reason: Dosage (500 mg) is precise, with no range or units needing clarification. Scientifically, this is a standard erythromycin dose, aligning with therapeutic norms for infections, leaving little room for error unless misheard, which isn’t indicated.

Choice C reason: Route (e.g., oral, IV) isn’t stated, critical for erythromycin, as administration affects bioavailability and efficacy. Scientifically, unclear delivery risks under- or overdosing, necessitating provider clarification to ensure safe, effective treatment per pharmacological standards.

Choice D reason: Time (four times daily) is clear, aligning with erythromycin’s pharmacokinetics for steady levels. Scientifically, frequency is unambiguous, requiring no clarification unless intervals were vague, which they aren’t, making this less urgent than route.

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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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