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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 B

Explanation

Rationale:

A. The client's length of facility stay: The duration of a client’s admission does not determine the appropriateness of delegation. Delegation decisions are based on the client’s current condition and the nature of the task, not how long they have been in the facility.

B. The AP's job description: Verifying the AP’s job description ensures the task falls within their authorized scope of practice. It helps confirm that the AP has the appropriate training and legal authority to carry out the delegated activity safely and competently.

C. The AP's years of experience: While experience may influence efficiency, it is not the primary factor in deciding what can be delegated. A newly trained AP may be competent for certain tasks, while years of experience do not guarantee suitability for all delegated care.

D. The client's age: Age alone does not dictate whether a task can be delegated. Delegation decisions depend more on the client's acuity, stability, and the complexity of care required, rather than demographic factors like age.

A. 300 mg PO od B. 3.0 mg PO gd C. 10.000 units IV dally D. 05 mL IM daily

Correct Answer is A

Explanation

Rationale:

A. 300 mg PO od: The dose is written clearly with no trailing zeros, and “od” (once daily) is acceptable though “daily” is preferred for clarity. This entry minimizes risk of misinterpretation and decimal errors.

B. 3.0 mg PO gd: Using a trailing zero (3.0 mg) increases the risk of a tenfold dosing error if the decimal point is missed. Also, “gd” is an incorrect abbreviation; “daily” or “once daily” should be used.

C. 10.000 units IV dally: Writing “10.000” with multiple trailing zeros is dangerous because the decimal point might be overlooked, causing a ten-thousand-fold error. Also, “dally” is a misspelling of “daily.”

D. 05 mL IM daily: Leading zeros before whole numbers (05 mL) are unnecessary and can cause confusion. The correct notation is “5 mL.” Leading zeros should only be used before decimals less than one (e.g., 0.5 mL).

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A nurse is preparing to delegate client care to an assistive personnel (AP). Which of the following information should the nurse verify prior to delegation?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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