As part of a follow-up home visit to an 80-year-old client who has had surgery, the nurse discusses the client's risk for delirium with his family members. Which of the following would the nurse NOT include as placing the client at increased risk?

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Question 1 of 5

As part of a follow-up home visit to an 80-year-old client who has had surgery, the nurse discusses the client's risk for delirium with his family members. Which of the following would the nurse NOT include as placing the client at increased risk?

Correct Answer: B

Rationale: The correct answer is B: Hypertension. Hypertension is not a risk factor for delirium in the context of a follow-up home visit after surgery. Delirium is commonly associated with factors such as urinary tract infections (A), acute stress (C), and bone fractures (D) in elderly clients. Hypertension, although a serious condition, does not directly contribute to the development of delirium in this scenario. Delirium is often multifactorial, with underlying medical conditions, infections, and stress being key contributors. In this case, the nurse would focus on discussing the client's risk factors such as urinary tract infections, acute stress, and bone fractures with the family members to prevent delirium.

Question 2 of 5

A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention?

Correct Answer: D

Rationale: The correct answer is D because massaging pressure points can cause skin breakdown in a child in skeletal traction. The pressure exerted during massage can lead to tissue damage and compromise skin integrity. This can result in pressure ulcers or sores, which can be extremely detrimental to the child's recovery. Providing a high protein snack (A) is beneficial for healing, assisting the child to reposition (B) helps prevent complications, and placing weights as a child's bed (C) is necessary for maintaining traction and should not be changed without proper authorization.

Question 3 of 5

Cognitive-behavioral therapy is going well when a 12-year-old patient in therapy reports to the nurse practitioner:

Correct Answer: B

Rationale: The correct answer is B because it demonstrates a cognitive restructuring process. The patient challenges a negative thought ("everyone at school hates me") with evidence to the contrary ("Most people like me and I have a friend named Todd"). This shows progress in identifying and changing maladaptive thought patterns. Choice A indicates aggression, choice C shows difficulty in implementing coping skills, and choice D suggests impulsivity without addressing underlying issues.

Question 4 of 5

Some cultures have lower rates of diagnosed conduct disorders than observed in Western societies. The lower rate of incidence may be contributed to:

Correct Answer: C

Rationale: The correct answer is C because parents' limited tolerance for externalizing behavior can lead to fewer cases of conduct disorders being diagnosed. This is because parents in these cultures may intervene and address behavioral issues before they escalate to the level of a diagnosed disorder. Choices A and B do not necessarily lead to lower rates of diagnosed conduct disorders, as strict parenting with corporal punishment can actually exacerbate behavior problems, and cultural expression of anger does not directly relate to conduct disorders. Choice D is incorrect because widespread acceptance of conduct disorders would likely lead to higher rates of diagnosis, not lower.

Question 5 of 5

Which assessment question regarding a patient's report of pain demonstrates the nurse's attention to the principles of holistic nursing care?

Correct Answer: D

Rationale: The correct answer is D because it addresses the patient's physical, emotional, and social well-being, aligning with holistic nursing care principles. It shows the nurse's consideration of the pain's impact on the patient's daily life. Options A, B, and C focus on specific aspects but do not encompass the holistic approach. Option A focuses only on the pain's timeline, option B on herbal supplements, and option C on familial history, neglecting the patient's overall well-being.

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