The nurse is caring for an assigned group of clients. Which client does the nurse identify as being at the highest risk for the development of delirium and will be closely monitored?

A client with a blood glucose level of 110 mg/dL (6.1 mmol/L).

A client who sustained a fractured femur in a motor vehicle crash.

An adult client being prepared for a laparoscopic cholecystectomy.

An older adult client with sepsis from a urinary tract infection.

Answer and Explanation

The Correct Answer is D

Choice A reason: This choice is incorrect. A blood glucose level of 110 mg/dL is within normal range and does not significantly increase the risk of delirium.

Choice B reason: While a fractured femur can be painful and stressful, it does not pose the highest risk for delirium compared to sepsis.

Choice C reason: Preparation for surgery can be a risk factor for delirium, but it is not as high a risk as sepsis in an older adult.

Choice D reason: This is the correct choice. Older adults with sepsis are at a high risk for delirium due to the systemic infection and its impact on overall health.

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Correct Answer is D

Explanation

Choice A reason: This choice is incorrect. Flooding is a diﬀerent technique from desensitization and involves intense and immediate exposure to the feared stimulus, which can be overwhelming and is not the gradual approach used in desensitization.
Choice B reason: This choice is incorrect. Simply teaching a patient to ignore or become immune to anxiety- producing situations does not address the underlying fear and is not a technique used in desensitization therapy.
Choice C reason: This choice is incorrect. While cognitive techniques may be part of a broader therapeutic approach, they are not the same as desensitization, which specifically involves gradual exposure combined with relaxation techniques.
Choice D reason: This is the correct choice. Desensitization therapy, also known as systematic desensitization, is a behavioral therapy technique that involves gradually exposing the patient to the feared object or situation while teaching them relaxation techniques to overcome their anxiety.

A. "Our child will sleep longer and could oversleep in the morning." B. "Our child may have some side eﬀects, like insomnia, loss of appetite, or weight loss." C. "Our child needs to take this medication once every 12 hours." D. "We'll bring our child in every week to get blood levels drawn."

Correct Answer is B

Explanation

Choice A reason: This choice is incorrect because stimulant medications used to treat ADHD are known to potentially cause insomnia rather than increased sleep duration.

Choice B reason: This is the correct choice. Common side eﬀects of stimulant medications for ADHD include insomnia, loss of appetite, and weight loss. These side eﬀects are well-documented and are important for parents to be aware of.

Choice C reason: This choice is incorrect. While the frequency of medication administration is important, the statement is too vague and does not reﬂect the common dosing schedule for ADHD stimulant medications, which can vary based on the specific medication and the individual's needs.

Choice D reason: This choice is incorrect. Routine blood level monitoring is not a standard requirement for ADHD stimulant medication therapy. Monitoring typically focuses on growth, blood pressure, heart rate, and the presence of any side eﬀects.

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The nurse is caring for an assigned group of clients. Which client does the nurse identify as being at the highest risk for the development of delirium and will be closely monitored?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a phobia asks, "What is desensitization therapy?" The best response is:

Correct Answer is D

Explanation

A 9-year-old patient with atention deficit hyperactivity disorder (ADHD) has been prescribed a stimulant. The nurse knows that the teaching has been eﬀective when the patient's parents make which statement?

Correct Answer is B

Explanation

An adolescent is being observed for atention deficit hyperactivity disorder (ADHD). Which circumstance would demonstrate evidence to support this diagnosis?

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The nurse is teaching the client with obsessive-compulsive disorder about reducing anxiety. Which would the nurse not include in teaching?

The nurse is caring for a client with obsessive-compulsive disorder (OCD). Which action by the nurse will increase the client's sense of security?

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