A nurse in an emergency department is assessing a client who was brought in by a caregiver. The caregiver reports that the client has had a change in behavior over the past 2 days. The nurse should identify which of the following findings as an indication that the client has delirium?
Select all that apply.

Aphasia

Hallucinations

Akathisia

Change in level of consciousness

Decreased attention span

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Aphasia, or difficulty with language, can occur in delirium due to acute disruption of cognitive processing. Clients may suddenly struggle to find words, understand speech, or communicate effectively. This is consistent with delirium’s hallmark of acute cognitive disturbance.

Choice B reason: Hallucinations are common in delirium, especially visual hallucinations. They result from acute brain dysfunction and fluctuating consciousness. Hallucinations are a key differentiating feature from dementia, which progresses gradually and is less likely to cause vivid perceptual disturbances in the early stages.

Choice C reason: Akathisia is a movement disorder characterized by inner restlessness and the inability to stay still, often caused by antipsychotic medications. While it may coexist in psychiatric clients, it is not a defining feature of delirium. Therefore, it is not an indicator of delirium.

Choice D reason: Change in level of consciousness is a hallmark of delirium. Clients may fluctuate between hyperalertness and lethargy, often within hours. This acute alteration distinguishes delirium from chronic cognitive disorders such as dementia.

Choice E reason: Decreased attention span is a core diagnostic feature of delirium. Clients are unable to focus, sustain, or shift attention appropriately. This impairment is often the earliest sign noticed by caregivers and clinicians.

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Correct Answer is D

Explanation

Choice A reason: Clients admitted involuntarily still retain the right to refuse medications unless a court order or emergency situation overrides this right. This statement is incorrect.

Choice B reason: Involuntary admission does not automatically mean a client is incompetent. Competency must be legally determined by a court, not assumed based on admission status.

Choice C reason: Restraints cannot be prescribed on an as-needed basis. They require a specific, time-limited order and must be used only when absolutely necessary to protect the client or others.

Choice D reason: Providers have a duty to warn identifiable individuals if a client makes a credible threat of serious harm. This is a legal and ethical responsibility to protect others from danger, making this the correct statement.

A. Request that the provider assess the client within 8 hr. B. Discontinue the seclusion if the client requests it. C. Document the client's behavior every 15 min while in seclusion. D. Request a PRN prescription for future seclusion.

Correct Answer is C

Explanation

Choice A reason: The provider must assess the client within 1 hour of initiating seclusion, not 8 hours. Delaying assessment violates safety protocols and legal requirements for restraint and seclusion use.

Choice B reason: Seclusion cannot be discontinued solely based on client request. It must be discontinued when the client demonstrates behavioral control and no longer poses a risk to themselves or others.

Choice C reason: Documenting the client’s behavior every 15 minutes is the correct action. Continuous monitoring ensures safety, evaluates effectiveness of seclusion, and provides legal documentation. This practice aligns with facility protocols and patient rights.

Choice D reason: Requesting a PRN prescription for future seclusion is inappropriate. Seclusion is a last-resort intervention and cannot be prescribed in advance. Each episode must be justified by current behavior and assessed individually.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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