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 C
Explanation
Rationale:
A. Respiratory acidosis: Chronic diarrhea typically causes metabolic acidosis due to loss of bicarbonate in the stool, not respiratory acidosis. Respiratory acidosis results from hypoventilation and CO₂ retention, unrelated to diarrhea.
B. Hypertension: Chronic diarrhea often leads to fluid and electrolyte imbalances causing hypotension or low blood pressure due to dehydration, rather than hypertension.
C. Hypokalemia: Diarrhea causes significant potassium loss through the gastrointestinal tract, leading to hypokalemia. Low potassium levels can result in muscle weakness, cramps, and cardiac arrhythmias.
D. Hypermagnesemia: Magnesium is usually lost during diarrhea, which more commonly leads to hypomagnesemia rather than elevated magnesium levels. Hypermagnesemia is rare unless there is excessive intake or renal failure.
Correct Answer is B
Explanation
Rationale:
A. "This medication prevents your baby from developing jaundice.": Phytonadione (vitamin K) does not play a role in bilirubin metabolism or the prevention of jaundice. Jaundice results from immature liver function and increased bilirubin levels, unrelated to vitamin K activity.
B. "This medication prevents your baby from developing bleeding problems.": Phytonadione is given to newborns to promote clotting factor synthesis and reduce the risk of hemorrhagic disease of the newborn. Newborns have low vitamin K stores at birth, making supplementation essential for preventing bleeding disorders.
C. "This medication enhances regulation of your baby's temperature.": Thermoregulation in newborns is managed by external warming and metabolic processes, not by vitamin K. Phytonadione has no impact on temperature control or thermal stability.
D. "This medication enhances your baby's immune response.": Vitamin K does not affect immune function. Its role is in coagulation, not immune system development or enhancement, and therefore does not influence infection prevention or immune strength.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.