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

Pantoprazole: Pantoprazole is a proton pump inhibitor commonly used to reduce stomach acid production. It is primarily indicated for the treatment of gastroesophageal reflux disease (GERD), peptic ulcers, and other conditions related to excessive stomach acid production. It does not play a role in managing Meniere's disease, which is a disorder of the inner ear characterized by episodes of vertigo, tinnitus, and hearing loss.

B) Warfarin: Warfarin is an anticoagulant medication used to prevent blood clot formation. It is commonly prescribed for conditions such as atrial fibrillation, deep vein thrombosis, and pulmonary embolism. Meniere's disease does not typically require anticoagulant therapy, so warfarin would not be indicated for its treatment.

C) Furosemide: Furosemide is a loop diuretic that helps reduce fluid retention by increasing urine output. In some cases of Meniere's disease, especially those associated with excessive endolymphatic fluid buildup in the inner ear, furosemide may be prescribed to help reduce fluid volume and alleviate symptoms such as vertigo and pressure sensation in the ear.

D) Oxybutynin: Oxybutynin is an anticholinergic medication primarily used to treat overactive bladder and urinary incontinence. It works by relaxing smooth muscle in the bladder, reducing bladder spasms and urinary urgency. While some individuals with Meniere's disease may experience associated symptoms such as frequent urination or urinary urgency, oxybutynin is not a standard treatment for Meniere's disease itself.

A. "Pentoxifylline can be administered to help the platelets from sticking together and occluding the vessels." B. "A heparin bolus is administered and followed with a continuous infusion to help keep the blood thinner." C. "A flexible catheter will be inserted into a vessel of the arm, neck, or groin and advanced to the heart to dilate a narrowed or occluded artery." D. "A small catheter with a balloon on the end is threaded into a vessel in the groin and advanced to the heart where the balloon will be inflated, and the narrowed valve will be dilated. "

Correct Answer is D

Explanation

A) "Pentoxifylline can be administered to help the platelets from sticking together and occluding the vessels": Pentoxifylline is a medication used to improve blood flow by decreasing the viscosity of blood. However, it is not typically used to treat mitral valve stenosis. This statement does not accurately reflect treatment options for this condition.

B) "A heparin bolus is administered and followed with a continuous infusion to help keep the blood thinner": Heparin is an anticoagulant used to prevent blood clot formation, but it is not a treatment for mitral valve stenosis itself. While anticoagulants may be used in certain situations with mitral valve stenosis (such as in the setting of atrial fibrillation), they do not directly address the underlying valve narrowing.

C) "A flexible catheter will be inserted into a vessel of the arm, neck, or groin and advanced to the heart to dilate a narrowed or occluded artery": This statement describes a procedure known as percutaneous transluminal mitral valvuloplasty (PTMV), which is a minimally invasive intervention used to treat mitral valve stenosis. During this procedure, a catheter with a deflated balloon on its tip is inserted into a vessel and guided to the heart, where the balloon is inflated to widen the narrowed valve.

D) "A small catheter with a balloon on the end is threaded into a vessel in the groin and advanced to the heart where the balloon will be inflated, and the narrowed valve will be dilated": This statement accurately describes balloon valvuloplasty, which is a common procedure used to treat mitral valve stenosis. By inflating the balloon within the narrowed valve, the procedure aims to widen the valve opening, thus improving blood flow through the heart.

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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 developing a plan of care for a client who has Meniere’s disease. Which of the following medications should the nurse anticipate administering?

Correct Answer is C

Explanation

A nurse is teaching a client who has mitral valve stenosis that has not responded to pharmacological therapies about other treatment options. Which of the following statements should the nurse include in their teaching?

Correct Answer is D

Explanation

A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

A nurse is providing discharge education to a client who has valvular heart disease and peripheral vascular disease. Which of the following should the nurse include in the teaching about valvular heart disease?

A nurse is assessing a client who reports manifestations of tinnitus. Which of the following actions should the nurse perform to determine if movement is causing the clients manifestations to worsen?

A nurse is providing CPR to a client. Which of the following aspects of CPR are different in the community versus in the hospital? (Select All that Apply.)

A nurse is providing care for a client following a cardiac arrest due to pulseless electrical activity (PEA). Which of the following alterations are causes of PEA? (Select All that Apply.)

Which of the following are risk factors for abdominal aortic aneurysm (AAA)? (Select all that apply.)

A nurse is teaching a client who has dilated cardiomyopathy (DCM) about this condition. Which of the following statements by the nurse should be included in the teaching?

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.)