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: Sitting positions the belt restraint safely at the waist, minimizing injury risk. It allows breathing and circulation, critical when managing aggression safely.
Choice B reason: Tying to bed rails restricts mobility excessively, risking injury if the bed moves. Proper restraint secures to a fixed frame, not rails.
Choice C reason: Chest placement impairs breathing, a dangerous error in restraint use. Belt restraints belong at the waist to avoid respiratory compromise.
Choice D reason: Under-clothing application risks skin abrasion and monitoring issues. Restraints over clothes ensure visibility and safety, per standard aggression protocols.
Correct Answer is A
Explanation
Choice A reason: Remeasuring confirms the 190/110 mm Hg reading, ensuring accuracy in kidney failure, where hypertension is common. It’s the first step before acting.
Choice B reason: Administering medication without verification risks error; BP may be inaccurate. In kidney failure, precise BP guides therapy, so this waits.
Choice C reason: Reporting to the charge nurse follows confirmation; unverified readings waste time. Accuracy in chronic kidney failure is critical before escalating.
Choice D reason: Bed rest may help, but confirming BP first prioritizes data. Kidney failure needs validated hypertension readings to direct immediate care safely.
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