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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor." This statement describes a mechanism associated with glaucoma, not cataracts. In cataracts, vision changes occur due to the opacity or cloudiness of the lens, not changes in intraocular pressure.
B) "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina." This statement describes a mechanism associated with retinal diseases like diabetic retinopathy, not cataracts. In cataracts, the lens becomes cloudy, affecting the passage of light through the eye.
C) "Vision changes occur when the cloudy lens alters the passage of light through the eye." This statement is correct. Cataracts cause the lens of the eye to become cloudy, which interferes with the passage of light through the eye. This results in vision changes such as blurred vision, glare, and difficulty seeing in low light conditions.
D) "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye." This statement describes a mechanism associated with retinal detachment, not cataracts. In cataracts, the lens becomes opaque, but the retinal tissue remains intact.
Correct Answer is D
Explanation
A) Hypoxia and acidosis While hypoxia and acidosis are serious complications of shock, they are physiological rather than psychological outcomes. These conditions primarily affect the body's metabolic and respiratory functions, rather than mental health or behavior.
B) Hearing deficits and increased risk of glaucoma Hearing deficits and increased risk of glaucoma are potential complications associated with certain medical conditions or medications but are not directly related to the psychological outcomes of shock. These conditions affect sensory perception (hearing and vision) rather than mental health or behavior.
C) Bipolar behaviors and schizotypal behaviors Bipolar behaviors and schizotypal behaviors are manifestations of mood and psychotic disorders, respectively, and are not typical adverse outcomes of shock. While psychological disturbances can occur in critically ill patients, they are not commonly characterized by specific psychiatric diagnoses like bipolar or schizotypal behaviors.
D) Disorientation and depression Disorientation and depression are common adverse psychological outcomes experienced by patients who have spent an extended period in the intensive care unit (ICU) due to complications related to shock. Prolonged ICU stays, medical interventions, sedation, and physical discomfort can contribute to feelings of confusion, disorientation, and depression in patients. Therefore, it is essential for the nurse to educate the client about these potential psychological effects and provide appropriate support and resources to address them during the transition to the medical unit.
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