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 ["A","B","C","D"]

Explanation

All of the following should be included in the teaching:

A. Living a sedentary lifestyle: Sedentary behavior, characterized by physical inactivity, is a risk factor for various cardiovascular conditions, including atrial fibrillation. Regular exercise is important for maintaining heart health and reducing the risk of atrial fibrillation.

B. Family history of atrial fibrillation: A family history of atrial fibrillation increases an individual's risk of developing the condition. Genetic factors play a role in predisposing individuals to atrial fibrillation, and having a close relative with the condition can elevate one's risk.

C. History of thyroid disease: Thyroid disorders, particularly hyperthyroidism (overactive thyroid), are associated with an increased risk of atrial fibrillation. Thyroid hormones influence heart rate and rhythm, and imbalances can predispose individuals to atrial fibrillation.

D. Recent influenza infection: Infections, particularly respiratory infections such as influenza, can trigger episodes of atrial fibrillation in susceptible individuals. The inflammatory response and physiological stress associated with infections can disrupt normal heart rhythm and precipitate atrial fibrillation episodes.

A. Encouraging increased mobility B. Dietary and fluid restrictions C. Cessation of intravenous (IV) drug use D. Cessation of hormonal supplements

Correct Answer is B

Explanation

A. Encouraging increased mobility: While mobility is important for overall health, it may not be the primary lifestyle modification emphasized in the discharge teaching for heart failure. The focus is typically on dietary and fluid restrictions, medication adherence, and symptom management.

B. Dietary and fluid restrictions: Dietary and fluid restrictions are essential lifestyle modifications for managing heart failure. Clients are often advised to follow a low-sodium diet and restrict fluid intake to prevent fluid retention and exacerbation of heart failure symptoms.

C. Cessation of intravenous (IV) drug use: While cessation of intravenous drug use is important for overall health and may be addressed if relevant to the client's situation, it may not be a primary focus of discharge teaching specifically related to heart failure.

D. Cessation of hormonal supplements: Cessation of hormonal supplements may be recommended if they contribute to heart failure or exacerbate its symptoms. However, this recommendation would be specific to individual client circumstances and may not apply to all clients with heart failure.

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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 teaching a group of clients about risk factors for developing atrial fibrillation. Which of the following should be included in the teaching?

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

Explanation

A nurse is providing discharge teaching to a client who has heart failure. Which of the following lifestyle modifications should the nurse include in the discharge teaching?

Correct Answer is B

Explanation

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