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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A reason: Shoulder harnesses at shoulder level secure the infant, distributing crash forces evenly. Scientifically, this aligns with safety standards, preventing spinal injury by stabilizing the torso, a critical car seat feature per biomechanical crash studies for optimal protection.
Choice B reason: A cushion under the head risks airway obstruction or spinal misalignment in crashes. Scientifically, added padding alters manufacturer design, increasing injury risk, as car seats are engineered for direct fit without extras per safety regulations.
Choice C reason: A 90-degree angle is upright, risking airway collapse in newborns with weak necks. Scientifically, a 30-45-degree recline supports breathing and spinal alignment, making this unsafe per pediatric and crash safety evidence.
Choice D reason: Airbags in the front seat can fatally injure infants in rear-facing seats via rapid inflation. Scientifically, back-seat placement avoids this, as airbag force exceeds infant tolerance, contradicting safety mandates for car seat positioning.
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