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?

WBC count 13,000/mm

Neuropathy

BUN 16 mg/dL

Hypertension

Answer and Explanation

The Correct Answer is A

A WBC count of 13,000/mm indicates infection, which is a common cause of delirium in older adults. Delirium is an acute confusional state that can result from various factors, such as medications, metabolic disturbances, sensory impairment, or environmental changes. Neuropathy, BUN 16 mg/dL, and hypertension are chronic conditions that do not directly cause delirium, although they may contribute to the client's overall health status.

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Correct Answer is B

Explanation

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

A. Edema B. Heart rhythm C. Temperature D. Intake

Correct Answer is B

Explanation

A client who has anorexia nervosa is at risk for cardiac arrhythmias due to electrolyte imbalances, dehydration, and malnutrition. The client's statement of feeling their heart jumping in their chest indicates a possible irregular heartbeat that should be reported to the provider. Edema, temperature, and intake are not as urgent as heart rhythm in this case.

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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

A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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