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: A 90-degree angle is too upright; newborns need a 30-45-degree recline to protect airways. This shows misunderstanding of safe positioning.

Choice B reason: Rear-facing until age 2 supports neck and spine safety, per guidelines. This reflects correct understanding of car seat standards for newborns.

Choice C reason: Retainer clips belong at chest level, not belly, for harness safety. This indicates incorrect knowledge of car seat strap placement.

Choice D reason: Airbags endanger front-seat infants; rear seating is mandatory. Enabling them shows a dangerous misunderstanding of car seat safety protocols.

A. "I have noticed that my child is withdrawn since we switched day care providers." B. "My child continually asks me the same questions." C. "My child still wets the bed at least two times per week." D. "I have a difficult time getting my child to eat green vegetables."

Correct Answer is A

Explanation

Choice A reason: Withdrawal after a day care switch may signal emotional distress or adjustment issues in a 4-year-old, potentially indicating anxiety or trauma. This behavioral change has psychosocial implications, prioritizing it for assessment, as it could affect development more acutely than physical habits per child psychology evidence.

Choice B reason: Repetitive questioning is normal for 4-year-olds, reflecting curiosity or language development, not a health priority. It lacks urgency compared to withdrawal, which may indicate deeper issues. Scientifically, this aligns with typical cognitive growth, not warranting immediate intervention over potential emotional distress signals.

Choice C reason: Bedwetting twice weekly at age 4 is within normal developmental variation, often resolving naturally. It’s less urgent than withdrawal, which could indicate psychological harm. Physiologically, bladder control matures later in some children, making this a lower priority per pediatric developmental norms.

Choice D reason: Difficulty eating vegetables is common in preschoolers due to taste preferences or neophobia, not a health crisis. It’s less critical than withdrawal, which may reflect emotional issues. Nutritionally, this can be addressed gradually, lacking the immediate psychosocial urgency of behavioral changes per evidence.

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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

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