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. .

Answer and Explanation

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. .

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Correct Answer is A

Explanation

Choice A rationale:

(Statement then rationale) Choice A is the correct option. A blood pH of 7.60 indicates severe metabolic alkalosis, which is a life-threatening condition. Metabolic alkalosis can lead to various complications, including cardiac arrhythmias, muscle weakness, and even seizures. Immediate intervention is required to address the underlying cause and correct the pH imbalance. The nurse should initiate treatments to restore the acid-base balance promptly.

Choice B rationale:

(Statement then rationale) Choice B is not the correct option. While a BUN level of 21 mg/dL is above the normal range, it alone does not require immediate intervention. Elevated BUN can be caused by various factors and may not be immediately life-threatening. It is important to assess the client's overall clinical condition and consider other lab values to make a comprehensive assessment.

Choice C rationale:

(Statement then rationale) Choice C is not the correct option. +2 edema of the lower extremities, while indicating fluid retention, is not an immediate life-threatening condition. Edema should be assessed and addressed, but it does not require emergency intervention as much as a severely altered blood pH does.

Choice D rationale:

(Statement then rationale) Choice D is also not the correct answer. Lanugo covering the body is a physical manifestation often seen in clients with anorexia nervosa and indicates malnutrition. While it is concerning and requires attention, it is not an acute, life-threatening issue. Nutritional rehabilitation and support are needed, but immediate intervention is necessary for the severe metabolic alkalosis indicated by a blood pH of 7.60. Now, let's proceed to the next question.

A. Aspartate aminotransferase 40 units/L. B. WBC 6,000/mm3. C. Sodium 132 mEq/L. D. Calcium 10.0 mg/dL.

Correct Answer is C

Explanation

Choice A rationale:

Aspartate aminotransferase (AST) is not directly related to lithium toxicity. Elevated AST levels are indicative of liver dysfunction or damage, not lithium toxicity.

Choice B rationale:

White blood cell (WBC) count within the normal range (6,000/mm3) is not a specific indicator of lithium toxicity. It is essential to focus on electrolyte and renal function parameters when assessing lithium toxicity.

Choice C rationale:

Low serum sodium levels (132 mEq/L) can place the client at risk for lithium toxicity. Hyponatremia, often caused by lithium-induced nephrogenic diabetes insipidus, can lead to impaired lithium excretion and increased risk of toxicity.

Choice D rationale:

A calcium level of 10.0 mg/dL is within the normal range and is not directly associated with lithium toxicity. Lithium toxicity primarily affects sodium levels, as mentioned earlier.

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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 is caring for a client who has anorexia nervosa.Which of the following findings requires immediate intervention by the nurse?

Correct Answer is A

Explanation

A nurse in a mental health facility is reviewing the laboratory results of a client who is taking lithium carbonate.Which of the following findings places the client at risk for lithium toxicity?

Correct Answer is C

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?