Which patient problem is a significant risk factor for the development of delirium in the intensive care unit (ICU)?

Type 2 diabetes mellitus

Alcohol abuse

Anxiety

Impaired communication

Answer and Explanation

The Correct Answer is B

Choice A reason: Type 2 diabetes mellitus, while a serious chronic condition, does not directly predispose patients to delirium. Diabetes primarily impacts the body's ability to regulate blood glucose levels, leading to complications such as cardiovascular disease, neuropathy, and nephropathy. However, it is not directly linked to the acute cognitive disturbances seen in delirium unless it leads to severe metabolic derangements, which is less common.

Choice B reason: Alcohol abuse is a significant risk factor for the development of delirium, especially in ICU patients. Chronic alcohol use can lead to a condition known as delirium tremens (DTs) during withdrawal, characterized by severe agitation, confusion, hallucinations, and autonomic hyperactivity. Patients with a history of alcohol abuse may have altered brain chemistry and neurotransmitter imbalances that predispose them to delirium when stressed by illness or surgery. Moreover, alcohol abuse can lead to liver dysfunction, nutritional deficiencies (particularly thiamine), and other systemic issues that further exacerbate the risk.

Choice C reason: Anxiety can exacerbate stress and discomfort in a patient but is not a primary causative factor for delirium. Anxiety may contribute to an increased sense of fear or confusion, especially in an ICU setting. However, it does not cause the profound disruption in cognitive function, attention, and awareness that characterizes delirium.

Choice D reason: Impaired communication might be a consequence or symptom seen in patients with delirium, but it is not a root cause. Patients with pre-existing communication difficulties might struggle more to express symptoms or needs, which could complicate care, but it does not inherently lead to the onset of delirium. Effective communication strategies and aids can help manage these challenges but do not address the underlying neurological changes seen in 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 C

Explanation

Choice A reason: NPH (Humulin N) is an intermediate-acting insulin that is used to control blood sugar levels throughout the day, not specifically for mealtime coverage. It is typically administered twice a day.

Choice B reason: Detemir (Levemir) is a long-acting insulin that provides basal insulin coverage. It helps maintain blood sugar levels stable over a 24-hour period and is not intended for controlling post-meal blood sugar spikes.

Choice C reason: Lispro (Humalog) is a rapid-acting insulin used for mealtime coverage. It is designed to be taken just before or immediately after a meal to control the sudden rise in blood sugar levels that occurs after eating.

Choice D reason: Glargine (Lantus) is a long-acting insulin that provides basal insulin coverage, helping to maintain steady blood glucose levels throughout the day and night. It is not used for mealtime blood sugar control.

A. Stage 2 B. Stage 1 C. Stage 3 D. Stage 4

Correct Answer is C

Explanation

Choice A reason: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Since the wound involves subcutaneous tissue, it exceeds the criteria for Stage 2.

Choice B reason: Stage 1 pressure injuries are characterized by non-blanchable erythema of intact skin. While the skin is still intact, it may appear red and not lighten when pressed. Given the description of a wound involving subcutaneous tissue, Stage 1 is not appropriate.

Choice C reason: Stage 3 pressure injuries involve full-thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, but the depth of tissue damage varies by anatomical location. This aligns with the wound involving subcutaneous tissue.

Choice D reason: Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While the wound described involves subcutaneous tissue, there is no mention of deeper tissue involvement, excluding Stage 4 classification.

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

Which patient problem is a significant risk factor for the development of delirium in the intensive care unit (ICU)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with diabetes is starting on insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?

Correct Answer is C

Explanation

A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?

Correct Answer is C

Explanation

The nurse works in a clinic located in a community where many of the residents are Hispanic. Which strategy, if implemented by the nurse, would decrease health care disparities and promote health equity for this community?

In any clinical setting, which health care team member is responsible for developing an individualized plan of care that includes nursing diagnoses, interventions, and outcomes, including the patient's self-management care plan?

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from a gastrointestinal hemorrhage. Which action can the nurse delegate to the nursing assistant (unlicensed assistive personnel)?

After reviewing the laboratory reports of a patient who was admitted with sudden severe abdominal pain, the nurse identifies that which condition is consistent with the test results?

Which outcome would the nurse include in the care plan for a patient with multiple sclerosis (MS)? Select all that apply.