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 C

Explanation

Choice A reason: Multiple motor and vocal tics are more indicative of Tourete syndrome, not autism spectrum disorder.
Choice B reason: Overly atached behavior is not typically associated with autism spectrum disorder; individuals with ASD may struggle with social atachments.
Choice C reason: This is the correct choice. Individuals with autism spectrum disorder often display a preference for solitary activities and may have difficulty forming friendships.
Choice D reason: An irresistible urge to pull out one's hair is characteristic of trichotillomania, not autism spectrum
disorder.

A. Asking questions easily answered with one-word responses is important with mental health clients. B. Invite the client's family to atend all group therapies with the client. C. Listen atentively to a client and summarize the comments. D. Avoid asking direct questions regarding suicidal behaviors or thoughts.

Correct Answer is C

Explanation

Choice A reason: This choice is incorrect. Asking questions that can be answered with one-word responses does not facilitate a deep therapeutic relationship.
Choice B reason: While involving the family can be beneficial, it is not a direct strategy for the nurse-client relationship.
Choice C reason: This is the correct choice. Active listening and summarizing are key components of building a therapeutic relationship, as they demonstrate understanding and validation of the client's feelings and thoughts.
Choice D reason: It is important to ask about suicidal behaviors or thoughts when there are indications of such risks; avoiding these questions can be detrimental to client care.

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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 9-year-old client who has been diagnosed with autism spectrum disorder would be expected to display which behavior?

Correct Answer is C

Explanation

A nurse is discussing strategies to develop nurse-client therapeutic relationships with a newly licensed nurse. Which statement by the nurse accurately describes strategies for building a therapeutic relationship?

Correct Answer is C

Explanation

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