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The nurse is reviewing the client's admission assessment to determine contributing factors to the client's change in mental status.

Exhibits
Click to highlight the findings that are risk factors. To deselect a finding, click on the finding again.

An older adult client was transferred to the ICU after they developed fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip arthroplasty.

The client is alert and oriented to person, place, and time.

Past Medical History: hypertension, congestive heart failure, Parkinson's disease

Social History: Client has visual loss without their glasses. The client is hard of hearing with hearing aids in place.

An older adult client

fever and hypotension

left hip fracture

total left hip arthroplasty

hypertension

congestive heart failure

Parkinson's disease

visual loss without their glasses

hard of hearing with hearing aids in place.

Answer and Explanation

The Correct Answer is ["A","B","D","G","H"]

Rationale:

• An older adult client is at high risk for delirium due to age-related changes in the brain and reduced physiological reserve. ICU environments and acute illness increase susceptibility in older adults. Age over 65 is a primary risk factor in many validated delirium screening tools.

• Fever and hypotension suggest a systemic infection and possible sepsis, which can impair cerebral perfusion. This can trigger acute confusion or delirium, especially in vulnerable individuals. The combination of infection and low blood pressure disrupts normal brain function.

• Total left hip arthroplasty involves major surgery and potential postoperative complications such as infection or pain. Surgical trauma, anesthesia, and immobility all increase delirium risk. Recent surgery also increases inflammatory cytokine activity affecting cognition.

• Past medical history: Parkinson’s disease is linked to higher delirium risk due to existing neurotransmitter imbalances. The condition often coexists with cognitive decline or medication interactions. Parkinson’s-related brain changes make acute confusion more likely.

• Visual loss without glasses limits sensory input and orientation cues, contributing to perceptual disturbances. Poor vision can lead to misinterpretation of surroundings, promoting hallucinations or paranoia. Environmental disorientation is a key factor in ICU-related delirium.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Eat foods high in vitamin B: Although B-vitamin deficiencies can contribute to stomatitis, eating foods high in vitamin B may not immediately relieve symptoms. Nutritional support is important long-term, but bland food recommendations provide immediate comfort.

B. Consume soft, bland foods: Soft, bland foods reduce mechanical and chemical irritation to the oral mucosa, promoting healing and reducing discomfort. These are ideal dietary choices for clients with stomatitis.

C. Rinse the mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can worsen irritation and dryness of the oral mucosa, aggravating stomatitis symptoms. Alcohol-free rinses or saline solutions are better alternatives.

D. Use lemon glycerin swabs: Lemon glycerin swabs can cause further drying and irritation of the mucosa. They are not recommended for clients with stomatitis, as they may intensify pain and inflammation.

A. Tilt the client's head forward during meals. B. Encourage socialization during meal times. C. Elevate the head of the client's bed to 30", D. Provide three large meals per day.

Correct Answer is A

Explanation

Rationale:

A. Tilt the client's head forward during meals: Tilting the head forward, also known as the chin-tuck technique, helps close the airway and reduce the risk of aspiration in clients with dysphagia. This position facilitates safer swallowing by improving bolus control and airway protection.

B. Encourage socialization during meal times: While social interaction is generally beneficial, clients with dysphagia require focused attention during meals to prevent choking or aspiration. Distractions can compromise concentration on swallowing techniques and safety precautions.

C. Elevate the head of the client's bed to 30": Although elevating the head of the bed helps reduce aspiration risk, a 30" elevation is not optimal for swallowing. A 45–90 degree upright position is typically recommended during meals to support safer swallowing mechanics.

D. Provide three large meals per day: Clients with dysphagia benefit more from small, frequent meals to reduce fatigue and lower the risk of aspiration. Large meals can overwhelm their ability to chew and swallow safely, increasing the risk of complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following prescriptions should the newly licensed nurse identify is an accurate transcription?

The nurse has reviewed the Vital Signs at 1000. Exhibits For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?

A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

A nurse working in an alternative therapy clinic is assisting in the care of a client who has elevated cholesterol levels. Which of the following should the nurse recommend?

A nurse is reinforcing teaching with a client who is at risk for hypertension. Which of the following risk reduction strategies should the nurse Include in the teaching?

A nurse is assisting with the care of a client in a provider's clinic. Exhibits For each finding of the client, click to specify if the finding is consistent with Hyperthyroidism or Hypothyroidism. Each finding may support more than one disease process.