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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Dark red urine signals active bleeding post-TURP, beyond expected light pink. It may indicate hemorrhage, requiring urgent provider intervention to prevent complications.
Choice B reason: 300 mL over 8 hr is adequate output post-TURP, not alarming. It aligns with expected bladder irrigation effects, needing no immediate report.
Choice C reason: Small clots are normal post-TURP as the prostate heals. Only large or persistent clots warrant concern, so this is an expected finding.
Choice D reason: Frequent urination urge is common post-TURP from bladder irritation. It’s not critical unless paired with obstruction, so it doesn’t need reporting.
Correct Answer is D
Explanation
Choice A reason: Persistent contractions signal labor or abruption, not previa. Placenta previa causes painless bleeding from placental positioning, not uterine activity.
Choice B reason: Increased fetal movement isn’t tied to previa; it’s a fetal response indicator. Previa’s hallmark is maternal bleeding, not fetal behavior changes.
Choice C reason: Rigid abdomen suggests abruption with clot formation, not previa. Previa bleeding is external, leaving the uterus soft, not tense.
Choice D reason: Bright red vaginal bleeding is classic in placenta previa, from low placental implantation. It’s painless, distinguishing it from other complications.
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