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 C

Explanation

A. Third spacing: Third spacing refers to the shifting of fluid from the intravascular space into the interstitial space, leading to decreased circulating volume. While third spacing can contribute to hypovolemic shock, it is not specific to obstructive shock.

B. Cardiomyopathy: Cardiomyopathy is a condition characterized by abnormalities in the heart muscle structure and function. While cardiomyopathy can lead to heart failure, it is not directly associated with obstructive shock.

C. Cardiac tamponade: Cardiac tamponade occurs when fluid accumulates in the pericardial sac, compressing the heart and impairing its ability to fill properly. This condition can lead to obstructive shock due to decreased cardiac output. Signs and symptoms include hypotension, muffled heart sounds, distended neck veins, and pulsus paradoxus.

D. Ruptured aneurysm: A ruptured aneurysm can lead to hypovolemic shock due to acute blood loss. While it can cause significant hemodynamic instability, it is not a characteristic diagnosis of obstructive shock.

A. Difficulty swallowing B. Shortness of breath C. Exertional fatigue D. Weight gain

Correct Answer is ["B","C"]

Explanation

A. Difficulty swallowing: Difficulty swallowing is not typically associated with atrial fibrillation. It may be a symptom of various other conditions such as dysphagia, esophageal disorders, or neurological disorders, but it is not a common manifestation of atrial fibrillation.

B. Shortness of breath: This is the correct answer. Shortness of breath, or dyspnea, is a common symptom of atrial fibrillation. Atrial fibrillation can lead to ineffective atrial contraction, resulting in decreased cardiac output and potential fluid accumulation in the lungs, leading to dyspnea.

C. Exertional fatigue: This is the correct answer. Exertional fatigue, or feeling excessively tired or weak with physical activity, is a common manifestation of atrial fibrillation. Reduced cardiac output and inefficient heart function due to irregular heart rhythms can lead to fatigue, especially during exertion.

D. Weight gain: Weight gain is not typically associated with atrial fibrillation. While some individuals with heart conditions may experience fluid retention and subsequent weight gain, it is not a specific manifestation of atrial fibrillation itself.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client experiencing obstructive shock. Which of the following diagnoses should the nurse expect?

Correct Answer is C

Explanation

A nurse is teaching a client who has symptomatic atrial fibrillation about manifestations to expect. Which of the following should the nurse include in the teaching? (Select All that Apply.)

Correct Answer is ["B","C"]

Explanation

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