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A nurse is caring for a group of clients in a pediatric clinic.
Which of the following clients is at the highest risk for physical abuse? .

A school-age child who wants to go away to summer camp.

A toddler who has cystic fibrosis.

An adolescent who is preparing to leave home for college.

A preschooler who is reluctant to share.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A school-age child wanting to go to summer camp is not at a higher risk for physical abuse.

Choice B rationale:

A toddler with cystic fibrosis is at a higher risk for physical abuse due to the stress and demands of caring for a child with a chronic illness.

Choice C rationale:

An adolescent preparing to leave home for college is not at a higher risk for physical abuse.

Choice D rationale:

A preschooler who is reluctant to share is not at a higher risk for physical abuse.

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Correct Answer is []

Explanation

Condition Most Likely Experiencing:

Delirium

The client's acute confusion, restlessness, disorientation, and inability to perform basic tasks suggest delirium rather than dementia or normal aging. Delirium often has an underlying cause, such as infection or medication side effects, and requires immediate intervention.

Actions to Take:

Monitor for an underlying infection.

Explanation: Infections, particularly urinary tract infections (UTIs) in older adults, are a common cause of delirium. Since the client has been incontinent, an infection could be contributing to the confusion. Identifying and treating the infection can help resolve symptoms.

Use symbols rather than written signs for directions.

Explanation: Since the client is confused and struggling to recognize basic instructions (e.g., confusing the call light with the TV remote), visual cues like symbols can help them navigate their environment and follow instructions more easily.

Parameters to Monitor:

Presence of agnosia.

Explanation: Agnosia (difficulty recognizing objects or their use) can indicate cognitive decline. The client mistaking a washcloth for something that belongs in a dryer suggests possible cognitive impairment, and tracking this symptom will help assess changes in mental status.

Ability to complete familiar tasks.

Explanation: Monitoring whether the client can complete daily activities (e.g., using the call light correctly, self-care) will help determine if their confusion is improving or worsening over time.

Incorrect Choices and Explanations:

Anticipate a prescription for donepezil.

Why Incorrect? Donepezil is used for Alzheimer’s disease, which develops gradually, unlike delirium, which is sudden and reversible if the cause is treated.

Anticipate a prescription for duloxetine.

Why Incorrect? Duloxetine is an antidepressant. While depression can cause confusion, this case strongly suggests acute delirium rather than major depressive disorder.

Determine the date of the client’s last eye examination.

Why Incorrect? Vision problems are not the primary concern in this case. The client's confusion is more likely related to delirium rather than visual impairment.

Night vision.

Why Incorrect? While vision problems can impact safety, the client’s confusion is the main issue here, not their ability to see at night.

Attendance at group therapy.

Why Incorrect? Group therapy is useful for conditions like depression or dementia but does not address the immediate, acute nature of delirium.

Oxygen saturation.

Why Incorrect? The client’s oxygen saturation is already normal (97%), making it an unlikely cause of the delirium. The focus should be on potential infection or other triggers.

A. Lower the window shade in the client's room. B. Obtain a PRN prescription for a vest restraint. C. Place the client in a room close to the nurses' station. D. Request a consult with recreational therapy.

Correct Answer is C

Explanation

Choice A rationale:

Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.

Choice B rationale:

Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.

Choice C rationale:

Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.

Choice D rationale:

While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.

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A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at the highest risk for physical abuse? .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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A nurse is caring for a group of clients in a pediatric clinic.
Which of the following clients is at the highest risk for physical abuse? .