The nurse is reviewing the client's admission assessment to determine contributing factors to the client's change in mental status.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Encourage client to swallow while advancing tube: Swallowing facilitates the passage of the nasogastric tube through the oropharynx and esophagus by closing the epiglottis and reducing the risk of the tube entering the trachea. This action helps guide the tube smoothly into the stomach.
B. Measure the length of the tube from client's nose to shoulder: Proper measurement involves extending the tube from the nose to the earlobe and then down to the xiphoid process, not just to the shoulder.
C. Place client in semi-Fowler's position in bed: The client should be placed in a high-Fowler’s position, not semi-Fowler’s, to promote comfort and reduce the risk of aspiration. This upright position also allows for easier passage of the tube through the upper GI tract.
D. Advance tube during client's inspiration: Advancing the tube during inspiration increases the risk of the tube entering the airway rather than the esophagus. The tube should be advanced when the client is swallowing, which helps direct it into the digestive rather than respiratory tract.
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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