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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Preschoolers (ages 3-5) often exhibit magical thinking, believing their actions cause events like death. This egocentric view links bad behavior to parental loss as punishment, reflecting their developmental stage where causality is self-focused, not abstract, aligning with typical grief responses in this age group scientifically.
Choice B reason: Understanding universal mortality requires abstract thinking, which develops later (around adolescence). Preschoolers lack this cognitive capacity, focusing instead on concrete, self-related explanations. This advanced comprehension is inconsistent with their developmental stage, making it an unlikely response to parental death in this age group.
Choice C reason: Recognizing permanent loss (never waking up) emerges around school age (6-12), not preschool. Younger children see death as reversible, like sleep, due to limited abstract reasoning. This understanding exceeds their developmental grasp, misaligning with typical preschool grief perceptions rooted in concrete thinking.
Choice D reason: Curiosity about funerals may occur, but it’s not a defining preschool grief trait. Their focus is more on magical thinking or separation anxiety, not procedural interest. This response, while possible, lacks the developmental specificity of self-blame, making it less consistent with scientific age-related grief patterns.
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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