A nurse is caring for a client in the intensive care unit. Which of the following laboratory values could contribute to an episode of delirium?

White blood cell level of 5,900 mm3

Potassium level of 4.1 mEq/L

Hemoglobin level of 14.2 g/dL

Blood glucose level of 254 mg/dL

Answer and Explanation

The Correct Answer is D

A. White blood cell level of 5,900 mm3: While abnormal white blood cell levels can indicate infection or inflammation, they are not typically associated with directly contributing to an episode of delirium. However, underlying conditions that cause abnormal white blood cell levels, such as infection or inflammation, may contribute to delirium.

B. Potassium level of 4.1 mEq/L: Potassium imbalances can lead to various neurological symptoms, including weakness, paralysis, and cardiac arrhythmias. However, a potassium level of 4.1 mEq/L is within the normal range and is unlikely to directly contribute to an episode of delirium.

C. Hemoglobin level of 14.2 g/dL: Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are not directly associated with delirium. While severe anemia or hypoxia can cause neurological symptoms, a hemoglobin level of 14.2 g/dL is within the normal range and is unlikely to directly contribute to delirium.

D. Blood glucose level of 254 mg/dL: Elevated blood glucose levels, as indicated by a blood glucose level of 254 mg/dL, can contribute to an episode of delirium. Hyperglycemia can lead to alterations in cerebral metabolism, neuronal dysfunction, and impaired cognitive function, predisposing individuals to delirium. Additionally, hyperglycemia can exacerbate preexisting neurological conditions and increase the risk of developing delirium in critically ill patients. Therefore, monitoring and managing blood glucose levels are essential in preventing and managing delirium in hospitalized patients.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "Note if you see any flashing bright lights on the grid." Flashing lights are not typically associated with macular degeneration. This symptom is more commonly associated with conditions like retinal detachment or migraine headaches.

B. "Check to see if the lines on the grid are blurry or distorted." This statement is correct. The Amsler grid is used to detect changes in central vision, which are common in macular degeneration. Patients with macular degeneration may perceive wavy or distorted lines instead of straight lines when looking at the grid, indicating central vision loss.

C. "Monitor for the lines on the grid to change in color or brightness." Changes in color or brightness of the lines on the grid are not typical features of macular degeneration. This statement does not accurately reflect the purpose of using an Amsler grid for macular degeneration.

D. "Watch for floating dark spots on the grid." Floating dark spots (floaters) are not typically associated with macular degeneration. Floaters are more commonly associated with conditions like posterior vitreous detachment or retinal detachment.

A. Administer pain medication as needed. B. Maintain ventriculostomy at the correct position. C. Maintain the neck in the midline position. D. Elevate the head of the bed to 150. E. Maintain enteral feedings.

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Administer pain medication as needed. Rationale: Pain management is essential for clients with traumatic brain injury (TBI) to ensure their comfort and to prevent agitation or increased intracranial pressure (ICP) due to pain. Administering pain medication as needed helps alleviate discomfort and promotes rest, which supports the client's recovery.

B. Maintain ventriculostomy at the correct position. Rationale: Ventriculostomy, also known as an external ventricular drain (EVD), is a critical component of managing intracranial pressure (ICP) in clients with traumatic brain injury. Maintaining the ventriculostomy at the correct position ensures accurate monitoring and drainage of cerebrospinal fluid (CSF), which helps control ICP levels and prevents complications such as cerebral edema.

C. Maintain the neck in the midline position. Rationale: Keeping the neck in a midline position is essential for clients with traumatic brain injury to prevent further injury to the cervical spine. Proper alignment of the neck helps maintain spinal stability and reduces the risk of exacerbating any existing spinal cord injury, which may coexist with the traumatic brain injury.

D. Elevate the head of the bed to 30 degrees. Rationale: Elevating the head of the bed to 30 degrees is recommended for clients with traumatic brain injury to promote cerebral venous drainage and reduce intracranial pressure (ICP). This position helps optimize cerebral perfusion and minimizes the risk of cerebral edema, which can occur with increased ICP.

E. Maintain enteral feedings. Rationale: Nutritional support is crucial for clients with traumatic brain injury to support healing and recovery. Enteral feedings, such as tube feedings, may be necessary if the client is unable to consume adequate nutrition orally due to impaired swallowing or altered consciousness. Providing enteral feedings ensures the client receives essential nutrients to support tissue repair and prevent malnutrition-related complications during the recovery process.

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A nurse is caring for a client in the intensive care unit. Which of the following laboratory values could contribute to an episode of delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has macular degeneration about how to use an Amsler grid. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

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