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?
Hypertension.
Neuropathy.
WBC Count 13,000/mm.
BUN 16 mg/dL. .
The Correct Answer is C
Choice A rationale:
Hypertension, while a medical condition, is not a direct risk factor for delirium. Delirium is typically associated with factors such as infection, medication side effects, metabolic imbalances, or acute changes in medical conditions, rather than chronic conditions like hypertension.
Choice B rationale:
Neuropathy is also not a direct risk factor for delirium. Delirium is more commonly associated with acute changes in neurological status or conditions that affect brain function.
Choice C rationale:
A white blood cell (WBC) count of 13,000/mm³ is an elevated count and may indicate an underlying infection or inflammation. Infection and inflammation are common causes of delirium, making an elevated WBC count a potential risk factor for developing delirium.
Choice D rationale:
A blood urea nitrogen (BUN) level of 16 mg/dL is slightly elevated but is not a direct risk factor for delirium. Delirium is more often associated with metabolic imbalances, electrolyte abnormalities, or acute changes in kidney function. A BUN level of 16 mg/dL alone is not a major contributor to delirium. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Increased appetite. Antidepressants may actually lead to decreased appetite in some individuals. Weight gain is a potential side effect, but it is often associated with increased appetite due to the improved mood that may lead to overeating, not as a direct side effect of the medication itself.
Choice B rationale:
Hypertension. Hypertension is not a common side effect of antidepressant use. While some medications may have cardiovascular side effects, they are generally not related to hypertension.
Choice D rationale:
Excessive energy. Antidepressants are not typically associated with increased energy levels. In fact, they are often used to treat symptoms of low energy and fatigue associated with depression.
Correct Answer is B
Explanation
Choice A rationale:
Obtaining consent from the client's family member is not the appropriate action in this scenario. The client has the right to make decisions about their own medical treatment, and the consent should come from the client themselves, not a family member.
Choice B rationale:
Informing the client that they have the legal right to refuse treatment at any time is the correct action. Informed consent is a fundamental principle of medical ethics, and the nurse should respect the client's autonomy and right to make decisions about their own healthcare.
Choice C rationale:
Requesting another nurse to review the procedure with the client may be helpful in providing additional information and support, but it does not address the client's right to refuse treatment. The primary responsibility is to ensure that the client is aware of their right to refuse.
Choice D rationale:
Encouraging the client to have the procedure goes against the principle of respecting the client's autonomy and right to make their own decisions about their healthcare. The nurse should not pressure the client into having the procedure.
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