A nurse is caring for a group of clients. After receiving bedside report, the nurse determines which of the following clients to be at greatest risk for developing delirium?

A client transferred to the medical unit 1 hour ago, after staying 3 days in the ICU for severe blood pressure issues

A client who has been on the medical unit for a week following a car accident and is waiting for transfer to a rehab facility when a bed becomes available

A client who has been NPO for 3 hours, receiving IV fluids, and has not been prescribed any medications

A client who is 4 days postoperative following knee surgery and scheduled for discharge home later this morning

Answer and Explanation

The Correct Answer is A

A. A client transferred to the medical unit 1 hour ago, after staying 3 days in the ICU for severe blood pressure issues: This client is at the greatest risk for developing delirium due to several factors: recent transfer from the intensive care unit (ICU), history of severe blood pressure issues requiring ICU admission, and the potential for experiencing significant physiological and psychological stressors during the ICU stay. Patients who have been in the ICU are at increased risk for delirium due to factors such as sedative use, mechanical ventilation, and critical illness.

B. A client who has been on the medical unit for a week following a car accident and is waiting for transfer to a rehab facility when a bed becomes available: While this client may have experienced significant trauma from the car accident, they have been stable on the medical unit for a week, which reduces the immediate risk of developing delirium compared to the client recently transferred from the ICU. However, ongoing assessment and monitoring are still necessary.

C. A client who has been NPO for 3 hours, receiving IV fluids, and has not been prescribed any medications: While fasting and receiving IV fluids may contribute to dehydration, which can increase the risk of delirium, this client does not have the same level of acuity or recent history of critical illness as the client transferred from the ICU. Additionally, the absence of prescribed medications reduces the risk of medication-related delirium.

D. A client who is 4 days postoperative following knee surgery and scheduled for discharge home later this morning: This client is in the subacute phase of recovery and is scheduled for discharge home, indicating stability and reduced risk of developing delirium compared to the client recently transferred from the ICU. However, postoperative patients are still at risk for delirium, particularly in the immediate postoperative period, and should be monitored accordingly.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Dopamine: Dopamine is a catecholamine often used to increase blood pressure and cardiac output in hypotensive states. It does not directly reduce intracranial pressure (ICP).

B. Mannitol: Mannitol is an osmotic diuretic commonly used to reduce intracranial pressure in clients with conditions such as subarachnoid hemorrhage, traumatic brain injury, or cerebral edema. It works by drawing fluid from brain tissue into the bloodstream, thereby reducing cerebral edema and ICP.

C. Nicardipine: Nicardipine is a calcium channel blocker used primarily to lower blood pressure in hypertensive emergencies. While it can indirectly impact intracranial pressure by reducing cerebral perfusion pressure, its primary mechanism of action is not targeted at reducing ICP.

D. Phenytoin: Phenytoin is an antiepileptic medication used to prevent and control seizures. While it may be indicated in clients who have experienced a subarachnoid hemorrhage to prevent seizures, it does not directly reduce intracranial pressure.

A. Changes to social cognition and challenges to inhibitory control B. Improved mood stability and improved temper control C. Improved rehabilitation outcomes and temporary behavior changes D. Sense of purpose, improved motivation, and stable relationships

Correct Answer is A

Explanation

A. Changes to social cognition and challenges to inhibitory control: Neurologic injuries such as increased intracranial pressure can lead to changes in social cognition, including difficulties in understanding social cues, interpreting emotions, and maintaining appropriate social interactions. Additionally, inhibitory control may be impaired, leading to impulsivity and disinhibition in behavior.

B. Improved mood stability and improved temper control: Neurologic injuries are more likely to result in mood instability and difficulties with temper control rather than improvement in these areas. Changes in mood, including irritability, anxiety, depression, and emotional lability, are common psychosocial consequences of neurologic injuries.

C. Improved rehabilitation outcomes and temporary behavior changes: While rehabilitation efforts may lead to improvement in functional abilities over time, neurologic injuries often result in persistent psychosocial challenges rather than improved outcomes. Temporary behavior changes may occur during the recovery process, but individuals may continue to experience long-term psychosocial sequelae.

D. Sense of purpose, improved motivation, and stable relationships: Neurologic injuries can significantly impact an individual's sense of purpose, motivation, and relationships. Clients may struggle to find meaning and motivation in their lives following a neurologic injury, and relationships may be strained due to changes in behavior, cognition, and communication.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a group of clients. After receiving bedside report, the nurse determines which of the following clients to be at greatest risk for developing delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse admits a client who has a subarachnoid hemorrhage and increased intracranial pressure (ICP). Which of the following medications should the nurse expect to administer to decrease ICP?

Correct Answer is B

Explanation

A nurse is reinforcing teaching to a group of nursing students about possible psychosocial changes a client might have after sustaining a neurologic injury such as increased intracranial pressure. Which of the following psychosocial changes should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following is an early manifestation of an AAA?

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following should the nurse understand is a risk factor for TBI?

A nurse is caring for a group of clients. After receiving bedside report, the nurse determines which of the following clients to be at greatest risk for developing delirium?

A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply.)

A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

A nurse is performing preoperative assessments on a client who has a suspected detached retina. Which of the following should the nurse expect to find?

A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)