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The nurse is reviewing the client's admission assessment to determine contributing factors to the client's change in mental status.

Exhibits
Click to highlight the findings that are risk factors. To deselect a finding, click on the finding again.

An older adult client was transferred to the ICU after they developed fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip arthroplasty.

The client is alert and oriented to person, place, and time.

Past Medical History: hypertension, congestive heart failure, Parkinson's disease

Social History: Client has visual loss without their glasses. The client is hard of hearing with hearing aids in place.

An older adult client

fever and hypotension

left hip fracture

total left hip arthroplasty

hypertension

congestive heart failure

Parkinson's disease

visual loss without their glasses

hard of hearing with hearing aids in place.

Answer and Explanation

The Correct Answer is ["A","B","D","G","H"]

Rationale:

• An older adult client is at high risk for delirium due to age-related changes in the brain and reduced physiological reserve. ICU environments and acute illness increase susceptibility in older adults. Age over 65 is a primary risk factor in many validated delirium screening tools.

• Fever and hypotension suggest a systemic infection and possible sepsis, which can impair cerebral perfusion. This can trigger acute confusion or delirium, especially in vulnerable individuals. The combination of infection and low blood pressure disrupts normal brain function.

• Total left hip arthroplasty involves major surgery and potential postoperative complications such as infection or pain. Surgical trauma, anesthesia, and immobility all increase delirium risk. Recent surgery also increases inflammatory cytokine activity affecting cognition.

• Past medical history: Parkinson’s disease is linked to higher delirium risk due to existing neurotransmitter imbalances. The condition often coexists with cognitive decline or medication interactions. Parkinson’s-related brain changes make acute confusion more likely.

• Visual loss without glasses limits sensory input and orientation cues, contributing to perceptual disturbances. Poor vision can lead to misinterpretation of surroundings, promoting hallucinations or paranoia. Environmental disorientation is a key factor in ICU-related delirium.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Prescribed epoetin V: Epoetin is used to stimulate red blood cell production, typically for anemia related to chronic kidney disease or chemotherapy. It is not a standard treatment for pernicious anemia and does not directly increase the client’s injury risk in this context.

B. Sleeps 8 to 10 hr per night: Sleeping 8 to 10 hours is within the normal range for many adults, particularly those recovering from fatigue associated with anemia. This finding does not pose any additional risk for injury.

C. Uses a firm-bristled toothbrush: A firm-bristled toothbrush can cause gum irritation or bleeding, especially in clients with anemia who may have fragile oral mucosa or concurrent thrombocytopenia. This increases the risk of oral injury or infection and should be avoided.

D. Prescribed vitamin B IM: Vitamin B12 IM injections are the standard treatment for pernicious anemia due to impaired intrinsic factor and poor absorption. This intervention helps correct the deficiency and prevent neurologic complications, not increase injury risk.

A. Dilated pupils B. Urinary retention C. Hypertension D. Tachypnea

Correct Answer is B

Explanation

Rationale:

A. Dilated pupils: Hydromorphone, an opioid, typically causes pupil constriction (miosis), not dilation. Dilated pupils may occur in opioid overdose only as a sign of severe hypoxia, but are not a common adverse effect of appropriate therapeutic dosing.

B. Urinary retention: Urinary retention is a known adverse effect of opioids like hydromorphone. Opioids can impair bladder muscle tone and suppress the urge to void by affecting central and peripheral nervous system pathways.

C. Hypertension: Hydromorphone generally causes hypotension due to vasodilation and histamine release. Hypertension is not a typical response and would more likely suggest untreated pain or another underlying condition.

D. Tachypnea: Opioids depress the respiratory center in the brain, which can lead to bradypnea rather than tachypnea. An increase in respiratory rate is not characteristic of opioid use unless it’s a response to severe, unmanaged pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is C

Explanation

A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?

Correct Answer is B

Explanation

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