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?
Amyloid plaque
Urinary tract infection
High cholesterol
Hypersomnia
The Correct Answer is B
Delirium is an acute, fluctuating disturbance in attention, cognition, and consciousness that develops over a short period of time. It is commonly triggered by an underlying medical condition, medication effect, or metabolic imbalance. Older adults and hospitalized clients are especially vulnerable. Identifying and treating the underlying cause is essential for reversing symptoms and preventing complications such as injury or prolonged cognitive impairment.
Rationale:
A. Amyloid plaque is associated with chronic neurodegenerative processes such as Alzheimer’s disease, which leads to gradual cognitive decline rather than the acute, fluctuating changes seen in delirium. While dementia increases vulnerability to delirium, amyloid plaques themselves are not an acute precipitating risk factor.
B. Urinary tract infection is a correct risk factor because infections are one of the most common reversible causes of delirium, especially in older adults. Infections such as Urinary tract infection can trigger systemic inflammation and metabolic changes that affect brain function, leading to acute confusion, restlessness, and disorientation.
C. High cholesterol is a long-term cardiovascular risk factor but is not directly associated with the acute onset of delirium. It contributes to chronic vascular disease over time rather than causing sudden cognitive changes. Therefore, it is not considered an immediate precipitating factor.
D. Hypersomnia refers to excessive sleepiness and is more commonly associated with sleep disorders, depression, or medication effects. It is not a known direct risk factor for delirium, which is characterized by acute confusion and fluctuating levels of consciousness rather than increased sleep duration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.25"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 0.25 mg
Available Concentration: 1 mg/mL
- Calculate the volume to administer
Volume (mL) = Ordered Dose ÷ Concentration
Volume = 0.25 ÷ 1
= 0.25 mL
Correct Answer is ["B","D","E"]
Explanation
Compartment syndrome occurs when increased pressure within a closed muscle compartment compromises circulation, nerve function, and tissue perfusion. It is a medical emergency that can lead to permanent nerve and muscle damage if not treated promptly. Early recognition is essential, especially after casting or trauma to an extremity. Nursing assessment focuses on the classic neurovascular changes known as “6 Ps,” including pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.
Rationale:
A. Decreased skin turgor is not associated with compartment syndrome and instead reflects dehydration or fluid volume deficit. It does not indicate localized neurovascular compromise in an extremity following casting. Therefore, it is unrelated to this condition.
B. Diminished capillary refill is a key sign of impaired perfusion due to increased compartment pressure. Reduced blood flow to the distal extremity indicates compromised vascular supply, which is a hallmark of Compartment syndrome. Delayed capillary refill requires immediate intervention to prevent irreversible tissue damage.
C. Pain relieved by analgesia is incorrect because pain in compartment syndrome is typically severe, unrelenting, and not relieved by standard analgesics. If pain is controlled with medication, it is less likely to indicate this condition. Instead, pain is often disproportionate to the injury and worsens with passive movement.
D. Sensation of tingling (paresthesia) is an early neurologic sign of nerve compression due to rising intracompartmental pressure. It indicates impaired sensory nerve function and is an important early warning of worsening ischemia. Prompt recognition is critical to prevent permanent nerve damage.
E. Pale-colored toes indicate reduced arterial blood flow to the distal extremity. Pallor reflects inadequate oxygenation and perfusion, which are characteristic findings in compartment syndrome. This requires urgent evaluation and possible surgical intervention such as fasciotomy.
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