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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Separate personalities are not a characteristic of schizophrenia; this is a common misconception. The disorder involving separate personalities is more accurately associated with dissociative identity disorder.
Choice B reason: While mood swings and hostility can occur in schizophrenia, they are not defining features of the disorder. Schizophrenia is primarily characterized by psychosis, which includes delusions and hallucinations.
Choice C reason: Preoccupation with somatic symptoms is more commonly associated with somatic symptom disorder, not schizophrenia. Schizophrenia involves a range of symptoms including cognitive and emotional dysfunctions.
Choice D reason: Thought disturbances, such as disorganized thinking, and hallucinations, particularly auditory ones, are hallmark symptoms of schizophrenia and are often used in its assessment.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Nonverbal cues can provide insight into a client's emotional state and intentions that may not be expressed verbally, especially when a client may not be able to communicate effectively due to their condition.
Choice B reason: While psychiatric disorders can affect verbal communication, this is not the primary reason nurses are encouraged to be aware of nonverbal communication.
Choice C reason: Clients may be guarded, but the primary reason for nurses to be aware of nonverbal communication is to gain additional information, not just because clients are guarded.
Choice D reason: Psychiatric disorders affecting thoughts more than physical behaviors does not explain why nonverbal communication is important.
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