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 D

Explanation

Choice A reason: Being married with children often buffers suicide risk by providing social support and purpose, reducing isolation—a key factor in depression. Scientifically, strong familial ties correlate with lower rates, making this a protective, not risk-enhancing, element in mental health assessments.

Choice B reason: Strong religious affiliation typically lowers suicide risk, as faith offers coping mechanisms and community, countering despair. Scientifically, studies show religiosity inversely relates to suicide, acting as a protective factor, not a contributor, in depression-related risk evaluations.

Choice C reason: A recent pay raise suggests improved financial stability, reducing stress—a suicide risk factor. Positive life events like this bolster resilience in depression, not heighten risk. Scientifically, this aligns with lower suicidal ideation, making it a protective rather than aggravating circumstance.

Choice D reason: Chronic back pain increases suicide risk in depression, as persistent pain erodes quality of life, amplifying hopelessness. Scientifically, chronic conditions correlate with higher rates, as physical suffering compounds psychological distress, making this a significant risk factor per mental health research.

A. Tape the tube to the child's cheek. B. Attach an extension tube to the site's opening prior to use. C. Secure the tubing to the child's abdomen. D. Apply water-soluble lubricant to the site.

Correct Answer is C

Explanation

Choice A reason: Taping to the cheek risks skin injury and tube displacement in kids. Abdominal securing is safer for gastrostomy stability and comfort.

Choice B reason: Extension tubes are for feeding, not routine site care. Attaching one now is premature, unrelated to maintaining the site itself.

Choice C reason: Securing to the abdomen prevents pulling or dislodgement of the gastrostomy tube. It’s a standard care step, ensuring stability and safety.

Choice D reason: Lubricant isn’t needed for site care; it may irritate skin. Clean, dry maintenance is preferred, making this an incorrect action.

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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 D

Explanation

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Correct Answer is C

Explanation

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