A 70yearold client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!"

Which of the following would be the most therapeutic response by the nurse?

"You need to come and take a shower before you can go get your hair cut."

"Please stop banging on the door. Your room is right over there."

"The door is locked so that you don't leave and get hurt."

"You are in the hospital, and I'm your nurse."

Answer and Explanation

The Correct Answer is C

A.   This response does not directly address the client's concern and may be perceived as dismissive.
B.   This response does not provide a clear explanation for the locked door and may not effectively address the client's agitation.
C.   This response provides a clear and honest explanation for the locked door, ensuring the client's safety, which is the priority.
D.   This response acknowledges the situation but does not provide a clear explanation for the locked door.

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Correct Answer is A

Explanation

A) Correct. Amitriptyline, like other tricyclic antidepressants, can cause orthostatic hypotension, which is a drop in blood pressure when changing position from lying to standing.

B) Incorrect. Diarrhea is not a common side effect of amitriptyline.
C) Incorrect. Weight gain is more commonly associated with amitriptyline, not weight loss.
D) Incorrect. Excessive salivation is not a typical side effect of amitriptyline.

A. A decreased level of consciousness with intermittent periods of hypervigilance. B. A slow onset of confusion and agitation. C. A decrease in the client's output and vital signs. D. The symptoms have lasted longer than a month.

Correct Answer is A

Explanation

A. Delirium is characterized by a fluctuating level of consciousness, which can include periods of hypervigilance.
B. A slow onset of confusion and agitation is more characteristic of dementia rather than delirium.
C. A decrease in output and vital signs may indicate a different condition, but it is not specific to delirium.
D. Delirium is characterized by an acute onset and is typically short-lived, usually lasting days to weeks. Symptoms lasting longer than a month would suggest a different diagnosis.

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Naxlex Comprehensive Predictor Exams

A client has been diagnosed with major depression and placed on amitriptyline. Which is a side effect of amitriptyline?

Correct Answer is A

Explanation

A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?

Correct Answer is A

Explanation

A 28-year old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?

A client with chronic alcoholism has been found to have Wernicke encephalopathy. What is this irreversible complication characterized by?

A nurse is preparing to administer fluoxetine 80 mg PO daily. Available is fluoxetine 40 mg/5mL. How many mL should the nurse administer per dose? (Write the number only, do not include the label. Record the answer to the nearest whole number. Do not use a trailing zero)

When assessing a client immediately following electroconvulsive therapy (ECT), the nurse expects what side effect in a client?

What intervention is a priority when the client is experiencing auditory hallucinations?

During the admission process, an elderly client is asked to present their license for identification purposes. The client gives the admission personnel their glasses. This is an example of which of the following symptoms of dementia?