A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

Hypersomnia

High cholesterol

Urinary tract infection

Amyloid plaque

Answer and Explanation

The Correct Answer is C

Choice A reason: Hypersomnia causes excessive sleep, not delirium’s acute confusion. It’s unrelated to the restlessness and disorientation seen in this client’s presentation.

Choice B reason: High cholesterol affects vessels, not acute brain function. It’s a chronic risk, not a trigger for delirium’s sudden cognitive shift here.

Choice C reason: UTIs in older adults often cause delirium via systemic inflammation and toxins. This matches the client’s disorientation and restlessness as a risk.

Choice D reason: Amyloid plaque links to Alzheimer’s, a chronic condition. Delirium is acute; plaque doesn’t explain the sudden onset in this scenario.

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Correct Answer is D

Explanation

Choice A reason: Increased caloric intake contradicts methylphenidate’s appetite-suppressant effect, a stimulant for ADHD. It boosts dopamine and norepinephrine, enhancing focus, not hunger. This suggests ineffectiveness or misreporting, as the drug typically reduces eating, misaligning with its pharmacological action on behavior.

Choice B reason: A better grasp of reality is vague and unrelated to ADHD or methylphenidate’s core effects. The drug improves attention and impulse control, not perception of reality, which is more relevant to psychosis. This does not indicate efficacy for ADHD scientifically.

Choice C reason: Weight loss is a common side effect of methylphenidate due to appetite suppression, not a direct efficacy marker. While it may occur, it does not confirm improved ADHD symptoms like focus, making it secondary to the drug’s therapeutic goal in treatment.

Choice D reason: Completing homework on time reflects improved focus and impulse control, methylphenidate’s primary goals in ADHD. By increasing dopamine in the prefrontal cortex, it enhances executive function, enabling task completion, a direct measure of efficacy per scientific intent.

A. Monitor the client for 1 hr after meals. B. Weigh the client every 2 days. C. Check the client's vital signs two times per week. D. Allow the client 2 hr to finish meals.

Correct Answer is A

Explanation

Choice A reason: Monitoring post-meals prevents purging, a common anorexia behavior. One hour ensures food retention, supporting nutritional recovery and countering compensatory actions effectively.

Choice B reason: Weighing every 2 days tracks trends, but daily is standard in anorexia to monitor refeeding risks like edema or cardiac strain more closely.

Choice C reason: Vital signs twice weekly miss acute changes in anorexia, like bradycardia from malnutrition. Daily checks are needed for safety during early treatment.

Choice D reason: Two hours per meal allows purging opportunities in anorexia. Shorter, supervised times prevent this, ensuring intake for nutritional rehabilitation success.

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A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

Explanation

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