A nurse is caring for a group of clients. After receiving bedside report, the nurse determines which of the following clients to be at greatest risk for developing delirium?

A client transferred to the medical unit 1 hour ago, after staying 3 days in the ICU for severe blood pressure issues

A client who has been on the medical unit for a week following a car accident and is waiting for transfer to a rehab facility when a bed becomes available

A client who has been NPO for 3 hours, receiving IV fluids, and has not been prescribed any medications

A client who is 4 days postoperative following knee surgery and scheduled for discharge home later this morning

Answer and Explanation

The Correct Answer is A

A. A client transferred to the medical unit 1 hour ago, after staying 3 days in the ICU for severe blood pressure issues: This client is at the greatest risk for developing delirium due to several factors: recent transfer from the intensive care unit (ICU), history of severe blood pressure issues requiring ICU admission, and the potential for experiencing significant physiological and psychological stressors during the ICU stay. Patients who have been in the ICU are at increased risk for delirium due to factors such as sedative use, mechanical ventilation, and critical illness.

B. A client who has been on the medical unit for a week following a car accident and is waiting for transfer to a rehab facility when a bed becomes available: While this client may have experienced significant trauma from the car accident, they have been stable on the medical unit for a week, which reduces the immediate risk of developing delirium compared to the client recently transferred from the ICU. However, ongoing assessment and monitoring are still necessary.

C. A client who has been NPO for 3 hours, receiving IV fluids, and has not been prescribed any medications: While fasting and receiving IV fluids may contribute to dehydration, which can increase the risk of delirium, this client does not have the same level of acuity or recent history of critical illness as the client transferred from the ICU. Additionally, the absence of prescribed medications reduces the risk of medication-related delirium.

D. A client who is 4 days postoperative following knee surgery and scheduled for discharge home later this morning: This client is in the subacute phase of recovery and is scheduled for discharge home, indicating stability and reduced risk of developing delirium compared to the client recently transferred from the ICU. However, postoperative patients are still at risk for delirium, particularly in the immediate postoperative period, and should be monitored accordingly.

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Correct Answer is B

Explanation

A. Dopamine: Dopamine is a catecholamine often used to increase blood pressure and cardiac output in hypotensive states. It does not directly reduce intracranial pressure (ICP).

B. Mannitol: Mannitol is an osmotic diuretic commonly used to reduce intracranial pressure in clients with conditions such as subarachnoid hemorrhage, traumatic brain injury, or cerebral edema. It works by drawing fluid from brain tissue into the bloodstream, thereby reducing cerebral edema and ICP.

C. Nicardipine: Nicardipine is a calcium channel blocker used primarily to lower blood pressure in hypertensive emergencies. While it can indirectly impact intracranial pressure by reducing cerebral perfusion pressure, its primary mechanism of action is not targeted at reducing ICP.

D. Phenytoin: Phenytoin is an antiepileptic medication used to prevent and control seizures. While it may be indicated in clients who have experienced a subarachnoid hemorrhage to prevent seizures, it does not directly reduce intracranial pressure.

A. Pericardiocentesis B. Septal myectomy C. Pericardial window D. Synchronized electrical cardioversion

Correct Answer is B

Explanation

A. Pericardiocentesis: Pericardiocentesis is a procedure used to drain fluid from the pericardial sac, typically performed in cases of pericardial effusion or cardiac tamponade. It is not indicated for the treatment of hypertrophic cardiomyopathy (HCM), which involves structural abnormalities of the heart muscle rather than pericardial fluid accumulation.

B. Septal myectomy: Septal myectomy is a surgical procedure performed to treat hypertrophic obstructive cardiomyopathy (HOCM), a subtype of hypertrophic cardiomyopathy characterized by thickening of the interventricular septum and dynamic left ventricular outflow tract obstruction. Septal myectomy involves the surgical removal of a portion of the hypertrophied septum to relieve left ventricular outflow tract obstruction and improve symptoms.

C. Pericardial window: A pericardial window is a surgical procedure used to create a communication between the pericardial sac and the pleural space, typically performed in cases of recurrent pericardial effusion or tamponade to prevent fluid re-accumulation. It is not indicated for the treatment of hypertrophic cardiomyopathy.

D. Synchronized electrical cardioversion: Synchronized electrical cardioversion is a procedure used to restore normal sinus rhythm in patients with certain types of cardiac arrhythmias, such as atrial fibrillation or atrial flutter. It is not typically indicated for the treatment of hypertrophic cardiomyopathy, although patients with HCM may develop arrhythmias as a complication.

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A nurse is caring for a group of clients. After receiving bedside report, the nurse determines which of the following clients to be at greatest risk for developing delirium?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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