Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","C","E","G"]

Explanation

Rationale:

Heart rate: A heart rate of 118/min indicates tachycardia, which may be a compensatory response to hypovolemia or blood loss. Combined with low blood pressure and low hemoglobin/hematocrit, it raises concern for active gastrointestinal bleeding and hemodynamic instability.
Stool results: A positive hemoccult test confirms gastrointestinal bleeding, especially when paired with the client’s report of dark, tarry stools (melena). This requires prompt evaluation and may indicate upper GI bleeding, such as from a peptic ulcer.
Current medications: The client is taking high-dose ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), which can cause or worsen gastric ulcers and bleeding. Continued use should be stopped immediately and replaced with safer alternatives.
WBC count: The WBC count is within the normal range and does not indicate an active infection or inflammatory process at this time. It does not require urgent follow-up compared to other findings.
Hemoglobin and hematocrit: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting blood loss likely due to GI bleeding. These values warrant urgent follow-up and possible transfusion depending on symptoms and stability.
Temperature: The client’s temperature of 37.5°C (99.5°F) is slightly elevated but within normal limits and not a priority concern. There are no signs of infection or fever that require immediate follow-up.
Blood pressure: A BP of 90/50 mm Hg indicates hypotension, which is concerning in the context of GI bleeding and low hemoglobin. This may reflect hypovolemia and requires prompt fluid management and monitoring.
Respiratory rate: A respiratory rate of 18/min is within normal limits and does not indicate respiratory distress. It does not require immediate follow-up in this context.

A. "You should replace your diaphragm every 2 year” B. "You should be refitted for your diaphragm if you have a 10 percent weight fluctuation." C. "You should insert the diaphragm when your bladder is full." D. "You should remove your diaphragm 4 hours after intercourse."

Correct Answer is B

Explanation

Rationale:

A. "You should replace your diaphragm every 2 years": Diaphragms generally need to be replaced every 1 to 2 years, depending on the manufacturer’s guidelines and wear and tear. However, it is more important to be aware of refitting needs related to physiological changes.

B. "You should be refitted for your diaphragm if you have a 10 percent weight fluctuation.": Significant weight changes, usually around 10 to 15 percent, can alter pelvic anatomy and affect diaphragm fit, increasing the risk of contraceptive failure. Therefore, refitting is recommended after notable weight fluctuations.

C. "You should insert the diaphragm when your bladder is full.": The bladder should be empty when inserting the diaphragm to avoid discomfort and ensure proper placement over the cervix. A full bladder can cause displacement and increase the risk of failure.

D. "You should remove your diaphragm 4 hours after intercourse.": The diaphragm should be left in place for at least 6 hours after intercourse to ensure adequate sperm immobilization and contraceptive effectiveness. Removing it too early may increase the risk of pregnancy.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is admitted to the medical-surgical unit Exhibits The nurse is reviewing the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["A","B","C","E","G"]

Explanation

A nurse is reinforcing teaching with a client who is using a diaphragm to prevent pregnancy. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath. and a respiratory rate of 24/min. Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

A nurse is caring for a client who has a prescription for furosemide, which of the following laboratory tests should the nurse monitor?

A nurse is assisting in the care of a group of clients who are postpartum. Which of the following clients should the nurse plan to see first?

A nurse is caring for a toddler who has impetigo. Which of the following actions should the nurse take?

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?

A nurse is assisting in the care of a client who has schizophrenia and is being prescribed a new antipsychotic medication. The client's parent asks the nurse not to discuss the medication side effects with the client. Which of the following ethical principles does this request violate?