The nurse is caring for an assigned group of clients. Which client does the nurse identify as being at the highest risk for the development of delirium and will be closely monitored?

A client with a blood glucose level of 110 mg/dL (6.1 mmol/L).

A client who sustained a fractured femur in a motor vehicle crash.

An adult client being prepared for a laparoscopic cholecystectomy.

An older adult client with sepsis from a urinary tract infection.

Answer and Explanation

The Correct Answer is D

Choice A reason: This choice is incorrect. A blood glucose level of 110 mg/dL is within normal range and does not significantly increase the risk of delirium.

Choice B reason: While a fractured femur can be painful and stressful, it does not pose the highest risk for delirium compared to sepsis.

Choice C reason: Preparation for surgery can be a risk factor for delirium, but it is not as high a risk as sepsis in an older adult.

Choice D reason: This is the correct choice. Older adults with sepsis are at a high risk for delirium due to the systemic infection and its impact on overall health.

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Correct Answer is D

Explanation

Choice A reason: Engaging the client in recreational activities may not be suitable during a panic atack as it might not address the immediate need for calm and safety.
Choice B reason: While medication can be helpful, the priority during a panic atack is to provide immediate, non- pharmacological support to ensure safety.
Choice C reason: Oﬀering therapy is beneficial but not the first-line intervention during an acute panic atack where immediate safety and reassurance are needed.
Choice D reason: This is the correct choice. The nurse should remain with the client to provide reassurance, assess their needs, and ensure safety during the panic atack.

A. "You need to tell those other patients to be quiet so I can sleep." B. "I feel really tired today, I'm gonna just rest for a while." C. "Look at my new purple hat; it goes well with my zebra-striped pants." D. "I can't go to therapy looking like this; my hair is a mess."

Correct Answer is C

Explanation

Choice A reason: This choice is incorrect. Requesting quiet to sleep does not necessarily support a diagnosis of a manic episode.
Choice B reason: This choice is incorrect. Feeling tired and wanting to rest is not indicative of a manic episode, which is typically characterized by increased energy and activity.
Choice C reason: This is the correct choice. The statement about the purple hat and zebra-striped pants suggests a lack of awareness of social norms and possibly grandiosity or ﬂamboyance, which can be indicative of a manic episode.
Choice D reason: This choice is incorrect. Concern about appearance does not specifically support a diagnosis of a manic episode.

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The nurse is caring for an assigned group of clients. Which client does the nurse identify as being at the highest risk for the development of delirium and will be closely monitored?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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