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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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Recommend the client spend time alone in his room: Isolation can worsen depressive symptoms by reducing social interaction and support. Clients with major depressive disorder benefit more from structured, supportive environments that encourage engagement.

B. Encourage the client to use positive self-talk: Promoting positive self-talk helps challenge negative thought patterns common in depression. This cognitive-behavioral strategy can improve mood, self-esteem, and overall coping ability.

C. Offer the client low-protein snacks throughout the day: Nutritional support is important, but there is no specific reason to offer low-protein snacks for depression. A balanced diet with adequate protein may better support brain function and mood regulation.

D. Suggest the client exercise before going to bed: Regular exercise is beneficial for managing depression, but exercising before bedtime can disrupt sleep patterns. Physical activity is better scheduled earlier in the day to promote restfulness at night.

A. Temperature B. WBC count C. Allergies D. Chest x-ray

Correct Answer is C

Explanation

Rationale:

• Temperature: An elevated temperature of 39.3° C is consistent with an active infection like pneumonia. This finding supports the need for antibiotic treatment and does not delay administration unless linked to an adverse drug reaction.

• WBC count: A WBC count of 16,000/mm³ indicates leukocytosis, which is expected in bacterial pneumonia. It confirms infection and the need for antibiotics, not a reason to withhold cefazolin.

• Allergies: The client has a documented allergy to penicillin, which is critical because cefazolin is a cephalosporin. Cephalosporins share a similar beta-lactam structure and can cross-react in clients with penicillin allergies, increasing the risk of anaphylaxis. Reporting this ensures safe prescribing and prevents a life-threatening hypersensitivity reaction.

• Chest x-ray: The left lower lobe density confirms pneumonia. This imaging supports the clinical decision to administer antibiotics and does not warrant withholding the prescribed medication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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