A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client approaches the nurse and states, "I’m going to take a walk outside. I'll be back in about 10 minutes." Which is the most appropriate nursing action?
Designate a staff member to accompany the client on the walk
Tell the client the walk is not allowed and restrict him to the unit
Further assess the client's motives for wanting to walk
Give the client permission to go on a walk on the grounds
The Correct Answer is A
Choice A reason: Mild delirium involves acute confusion and impaired judgment due to cerebral dysfunction, often from metabolic or infectious causes. Accompanying the client ensures safety, as disorientation increases wandering or injury risk. Supervision mitigates risks from altered cognition while allowing mobility, supporting cerebral recovery without exacerbating confusion.
Choice B reason: Restricting the client to the unit may increase agitation, as delirium’s neurochemical imbalances, like acetylcholine deficiency, heighten restlessness. While safety is critical, blanket restriction ignores the potential benefits of supervised movement, which can reduce stress and improve cerebral perfusion, making this less appropriate than supervised accompaniment.
Choice C reason: Assessing motives may clarify intent but delays addressing immediate safety in delirium, where confusion stems from cerebral dysfunction, such as hypoxia or electrolyte imbalance. The client’s impaired judgment requires supervision over exploration of motives, as disorientation increases risk of harm, making this a secondary action.
Choice D reason: Allowing an unsupervised walk is unsafe in delirium, as acute cognitive impairment from neurotransmitter imbalances or metabolic disturbances increases wandering or injury risk. Without supervision, the client may become disoriented or lost, exacerbating cerebral stress. Accompanied walks better balance safety and mobility in this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Depression involves slowed cognitive processing due to serotonin and prefrontal cortex dysfunction, causing delayed responses. Allowing time respects this neurobiological delay, reducing pressure and potential withdrawal. This supports engagement, as the client may formulate a goal with patience, aligning with therapeutic strategies for depressive cognitive deficits.
Choice B reason: Prompting for a response may increase anxiety in depression, where serotonin dysregulation impairs cognitive fluency. Immediate pressure risks disengagement, as the client’s slowed prefrontal processing struggles to respond quickly. Allowing time is more effective, as it accommodates the neurobiological delays characteristic of depressive cognitive function.
Choice C reason: Moving to the next client dismisses the depressed client’s engagement, exacerbating feelings of worthlessness linked to serotonin and dopamine imbalances. This risks reinforcing social withdrawal, a common depressive symptom, as the client’s prefrontal cortex struggles with participation. Allowing time supports inclusion and respects cognitive delays.
Choice D reason: Offering a goal suggestion may reduce autonomy in depression, where prefrontal cortex dysfunction already impairs decision-making. This risks dependency rather than empowering the client, whose serotonin-related cognitive delays require patience to formulate personal goals, making this less effective than allowing time for self-directed thought.
Correct Answer is D
Explanation
Choice A reason: Orientation to person but disorientation to place and time occurs in both delirium and dementia. In delirium, acute cerebral dysfunction from causes like infection disrupts attention, while dementia’s gradual hippocampal loss affects memory. This symptom is non-specific, as it does not distinguish the acute onset critical to delirium diagnosis.
Choice B reason: Fragmented, incoherent speech can occur in delirium due to acute brain dysfunction or in advanced dementia from cortical degeneration. It reflects disrupted neural communication but is not specific to delirium’s rapid onset. This symptom alone does not differentiate the conditions, as both involve cognitive processing deficits.
Choice C reason: A history of increasing confusion over years indicates dementia, characterized by progressive neuronal loss, particularly in Alzheimer’s or vascular dementia. Delirium, conversely, has an acute onset due to reversible causes like infection. This chronic history rules out delirium, making this choice incorrect for identifying delirium.
Choice D reason: Being oriented and alert on admission, then developing confusion, indicates delirium’s acute onset, typically from pneumonia-related hypoxia or sepsis disrupting cerebral metabolism. Unlike dementia’s gradual progression, delirium’s rapid cognitive decline, often within days, reflects reversible brain dysfunction, making this the key differentiator in diagnosis.
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