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 A

Explanation

Choice A reason: Injecting 15 units of air into regular insulin balances vial pressure, per protocol. This step precedes drawing regular insulin, ensuring accurate mixing sequence.

Choice B reason: Withdrawing NPH now skips regular insulin prep, risking contamination or error. Air injection into both vials comes first in standard insulin administration.

Choice C reason: Verification is key but follows insulin preparation. Air injection sequence precedes dosage checks, making this premature before completing vial prep steps.

Choice D reason: Capping the needle halts the process prematurely. Air must be injected into both vials first to maintain sterile technique and accurate dosing.

A. Encourage the client to use the overbed trapeze. B. Maintain abduction of the client’s residual limb with a pillow. C. Caution the client to avoid a prone position while in bed. D. Keep a loose, absorbent dressing over the client’s surgical site.

Correct Answer is A

Explanation

Choice A reason: Using a trapeze builds upper body strength, aiding transfers and mobility post-amputation. Scientifically, this promotes independence by enhancing muscle power for prosthetic use, aligning with rehabilitation goals to restore function and reduce reliance on others early in recovery.

Choice B reason: Abduction with a pillow prevents adduction contractures but doesn’t directly enhance mobility. It’s passive, not active, support. Scientifically, while useful, it lacks the progressive impact of strength training, making it secondary to fostering independence in amputation care.

Choice C reason: Avoiding prone position is outdated; prone lying prevents hip flexion contractures, aiding mobility. Scientifically, this caution hinders rehabilitation, as stretching the hip flexors supports prosthetic alignment and walking, contradicting progression toward independence.

Choice D reason: Loose dressings don’t promote mobility; tight, controlled dressings reduce edema for prosthetic fitting. Scientifically, this delays healing and strength-building, as proper wound management, not loose coverage, supports physical progression in amputation recovery.

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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 A

Explanation

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Correct Answer is A

Explanation

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