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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice b, Blood pressure.
Rationale for Choice a, Bowel sounds:
- Bowel sounds are not directly relevant to the potential interaction between phenelzine and pepperoni pizza.
- While assessing bowel sounds is a part of a comprehensive nursing assessment,it would not be the top priority in this specific scenario.
- Phenelzine does not typically cause gastrointestinal disturbances that would warrant immediate assessment of bowel sounds.
Rationale for Choice c, Oxygen saturation:
- Oxygen saturation is not directly affected by the interaction between phenelzine and pepperoni pizza.
- Assessing oxygen saturation would be more pertinent in situations involving respiratory distress or hypoxia.
- There is no evidence to suggest that this interaction would cause respiratory depression or compromise oxygen saturation levels.
Rationale for Choice d, Pupil response:
- Pupil response is not a reliable indicator of the potential complications associated with phenelzine and tyramine-rich foods.
- It's primarily assessed for neurological conditions or drug intoxication affecting the central nervous system.
- The interaction between phenelzine and tyramine primarily affects the cardiovascular system,not the neurological system.
Rationale for Choice b, Blood pressure:
- Blood pressure is the most critical assessment in this scenario due to the potential for a hypertensive crisis.
- Phenelzine is a monoamine oxidase inhibitor (MAOI),which blocks the breakdown of tyramine,a substance found in certain foods like pepperoni,aged cheeses,and fermented products.
- When tyramine levels increase,it can trigger a sudden and severe rise in blood pressure,known as a hypertensive crisis.
- Symptoms of a hypertensive crisis can include:
- Severe headache
- Neck stiffness
- Chest pain
- Nausea
- Vomiting
- Blurred vision
- Sweating
- Photophobia (sensitivity to light)
- Palpitations
- Anxiety
- Confusion
- Seizures
- Stroke
- Potentially death
- Prompt assessment of blood pressure is crucial for early detection and intervention to prevent these life-threatening complications.
Correct Answer is C
No explanation
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