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 ["A","B","C","D","E","F"]
Explanation
Choice A reason: Knowing if the family is aware can help in understanding the client's support system.
Choice B reason: Understanding the method the client is considering can help assess the level of risk and immediacy.
Choice C reason: Knowing the timing can help in immediate risk assessment and prevention planning.
Choice D reason: Assessing access to means is crucial for immediate safety planning.
Choice E reason: Understanding if there is a specific plan can help gauge the seriousness and immediacy of the risk.
Choice F reason: Offering spiritual or emotional support can be an important part of the care plan.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect as prescribing medications is not within the scope of practice for a basic- level psychiatric-mental health nurse.
Choice B reason: Conducting family therapy typically requires advanced training and is not usually within the scope of a basic-level nurse.
Choice C reason: Interpreting laboratory tests is generally not within the scope of a basic-level psychiatric-mental health nurse.
Choice D reason: This is the correct choice. Promoting symptom management is an appropriate intervention for a psychiatric-mental health nurse at the basic level of practice.
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