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. People who abstain from alcohol: Abstaining from alcohol does not necessarily increase the risk of sustaining a traumatic brain injury (TBI). In fact, excessive alcohol consumption can increase the risk of falls and accidents leading to TBIs, but abstaining from alcohol itself is not a risk factor for TBI.

B. People who live in rural areas: Living in rural areas may be associated with certain risk factors for TBIs, such as increased rates of motor vehicle accidents due to factors like higher speed limits and longer distances traveled. However, it is not a direct cause of TBIs.

C. People who play contact sports: Engaging in contact sports, such as football, soccer, or rugby, poses a higher risk of sustaining a traumatic brain injury due to the potential for collisions, falls, and impacts during gameplay.

D. People who are in their 30's: While traumatic brain injuries can occur at any age, individuals who are involved in activities with a higher risk of head injuries, such as contact sports or high-risk occupations, may be more prone to TBIs regardless of their age. Age alone is not a significant risk factor for TBIs.

A. Rheumatoid arthritis B. Bacterial pneumonia C. Macular degeneration D. Osteoporosis

Correct Answer is A

Explanation

A. Rheumatoid arthritis: Rheumatoid arthritis is an autoimmune condition characterized by chronic inflammation of the joints. Some research suggests a possible link between autoimmune disorders such as rheumatoid arthritis and Meniere's disease. Autoimmune conditions can affect the inner ear, leading to vestibular dysfunction and contributing to the development of Meniere's disease.

B. Bacterial pneumonia: Bacterial pneumonia is a respiratory infection caused by bacterial pathogens. There is no direct association between bacterial pneumonia and an increased risk of developing Meniere's disease. Meniere's disease primarily affects the inner ear and is not related to respiratory infections.

C. Macular degeneration: Macular degeneration is a degenerative eye disease that affects the central portion of the retina. There is no known association between macular degeneration and an increased risk of developing Meniere's disease. These conditions affect different parts of the body and are not related in terms of etiology or risk factors.

D. Osteoporosis: Osteoporosis is a condition characterized by loss of bone density, leading to an increased risk of fractures. There is no direct association between osteoporosis and an increased risk of developing Meniere's disease. These conditions affect different systems in the body and are not known to be related.

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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

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following groups should the nurse understand has a higher risk of sustaining a TBI?

Correct Answer is C

Explanation

A nurse is teaching a client about health conditions that increase the risk for developing Meniere’s disease. Which of the following factors should the nurse include in the teaching?

Correct Answer is A

Explanation

The spouse of an older client experiencing delirium is at the client's bedside. The nurse is providing an update to the spouse regarding the client's plan of care. Which of the following responses by the spouse indicates a need for further teaching?

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A nurse is assessing a client who is experiencing an episode of tinnitus. Which of the following statements from the client indicates that the tinnitus might be affecting their well-being?

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