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 B
Explanation
Choice A reason: This statement is incorrect because stimulants used to treat ADHD can actually cause insomnia and might reduce the amount of sleep a child gets.
Choice B reason: This is the correct statement. Parents acknowledging the potential side effects of stimulant medications, such as insomnia, loss of appetite, or weight loss, indicates an understanding of the medication's effects.
Choice C reason: This statement could be correct depending on the specific medication prescribed, but it does not reflect an understanding of the potential side effects, which is crucial for managing the child's care.
Choice D reason: Regular blood level checks are not typically required for ADHD stimulant medications, so this statement does not indicate effective teaching about the medication.
Correct Answer is B
Explanation
Choice A reason: While it's important to provide support, simply telling the client they have nothing to be ashamed of does not address the underlying issues or feelings the client may be experiencing.
Choice B reason: This response opens a dialogue and allows the client to share their experiences and challenges since the last admission, fostering a therapeutic relationship and understanding.
Choice C reason: This statement could be perceived as judgmental and may make the client feel worse, potentially hindering the therapeutic relationship.
Choice D reason: Asking why they started drinking again could come across as accusatory and may cause the client to become defensive or feel guilty, which is not conducive to recovery.
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