A nurse is assisting in the care of clients on a postpartum unit. Which of the following events should the nurse identify as needing to initiate a security alert for?

An assistive personnel weighs and bathes the newborn in an empty client room

Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening

The caregiver and newborn have matching hospital identification bracelets

A hospital volunteer leaves the unit with the newborn to allow caregiver to rest

Answer and Explanation

The Correct Answer is D

A. An assistive personnel weighs and bathes the newborn in an empty client room: While this may not be ideal practice depending on facility policy, it does not necessarily indicate a security threat unless the newborn is removed from secured areas without authorization.

B. Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening: It is common for nurses to transport newborns for necessary procedures, provided proper identification protocols are followed. This situation does not automatically trigger a security alert.

C. The caregiver and newborn have matching hospital identification bracelets: Matching ID bracelets are part of the standard safety protocol to ensure correct infant identification and prevent abduction. This situation demonstrates proper security measures.

D. A hospital volunteer leaves the unit with the newborn to allow the caregiver to rest: Volunteers are not authorized to transport newborns outside of secured areas. This action represents a serious breach of security and requires the immediate initiation of a security alert to prevent potential abduction or harm.

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Correct Answer is B

Explanation

A. Amyloid plaque: Amyloid plaque buildup is characteristic of Alzheimer’s disease, a chronic, progressive form of dementia. While dementia can increase the overall risk for delirium, amyloid plaques themselves are not an immediate trigger for acute confusion like delirium.

B. Urinary tract infection: Urinary tract infections are a common reversible cause of delirium, especially in older adults. Infections can trigger a systemic inflammatory response and disrupt normal brain function, leading to sudden-onset confusion, disorientation, and restlessness due to systemic inflammation and changes in metabolic balance.

C. High cholesterol: High cholesterol contributes to long-term cardiovascular risks, such as atherosclerosis and stroke, but it is not directly linked to the sudden cognitive changes seen in delirium. It does not cause the acute neurological dysfunction characteristic of delirium.

D. Hypersomnia: Hypersomnia, or excessive daytime sleepiness, may reflect underlying sleep disorders or other chronic conditions, but it is not recognized as a common direct cause of delirium. Acute changes in mental status are more often tied to factors like infection, medications, or metabolic disturbances.

A. Dry skin B. Hypotension C. Constipation D. Urinary retention

Correct Answer is B

Explanation

A. Dry skin: Dry skin is not typically associated with the disulfiram-alcohol reaction. The primary concerns involve cardiovascular and gastrointestinal symptoms rather than dermatologic effects.

B. Hypotension: Disulfiram causes an intense physical reaction when alcohol is consumed, including symptoms like flushing, nausea, vomiting, hypotension, and potentially life-threatening cardiovascular collapse. Monitoring for hypotension is critical during this reaction.

C. Constipation: Constipation is not a typical side effect of disulfiram-alcohol interaction. Gastrointestinal symptoms such as nausea and vomiting are much more common and more clinically significant.

D. Urinary retention: Urinary retention is not a known reaction to the combination of disulfiram and alcohol. The body’s response focuses more on vascular changes and gastrointestinal distress.

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A nurse is assisting in the care of clients on a postpartum unit. Which of the following events should the nurse identify as needing to initiate a security alert for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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