A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

BUN 16 mg/dL.

Neuropathy.

WBC count 13,000/mm².

Hypertension.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. WBC count 13,000/mm².

Choice A rationale:

A BUN (Blood Urea Nitrogen) level of 16 mg/dL is within the normal range (7-20 mg/dL) and does not indicate an increased risk for delirium.

Choice B rationale:

Neuropathy, while a significant condition, is not directly associated with an increased risk of delirium. Delirium is more commonly linked to acute changes in health status.

Choice C rationale:

An elevated WBC count of 13,000/mm² indicates an infection or inflammation, which can increase the risk of delirium, especially in older adults or those with compromised health.

Choice D rationale:

Hypertension is a chronic condition that does not directly increase the risk of delirium. Delirium is more often associated with acute medical conditions or changes.

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Correct Answer is B

Explanation

Choice A rationale:

Documenting the client's behavior every 15 minutes is a valid nursing action when a client is placed in seclusion. However, it is not the most critical step to take in this situation. The safety and well-being of the client and staff are paramount, and obtaining the provider's prescription is more crucial.

Choice B rationale:

The correct choice. Obtaining the provider's prescription within 60 minutes is essential when a client is placed in seclusion. Seclusion is an intervention that restricts the client's freedom, and it should only be done under the supervision of a licensed healthcare provider. The nurse must obtain a prescription for this intervention as soon as possible to ensure that the client's rights and safety are respected.

Choice C rationale:

Offering the client food and fluids every 2 hours is a valid nursing action in a seclusion situation. However, it is not the most immediate priority. Obtaining the provider's prescription takes precedence to ensure the appropriateness of the intervention.

Choice D rationale:

Monitoring the client's vital signs every 4 hours is an important nursing action, but it is not the primary step to take immediately after placing a client in seclusion. Obtaining the provider's prescription is more urgent to ensure the legality and appropriateness of the intervention.

A. Ask the client to sign a no-suicide contract. B. Implement continuous one-to-one observation. C. Establish a rapport to foster trust. D. Encourage the client to participate in group therapy.

Correct Answer is B

No explanation

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A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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