A nurse is assessing a client who has delirium as a result of sepsis. Which of the following manifestations should the nurse expect? (Select all that apply.)

Slow speech.

Rapid mood changes.

Hallucinations.

Unaltered level of consciousness.

Restlessness.

Answer and Explanation

Correct Answer : B,C,E

A reason: Slow speech. Slow speech is not typically associated with delirium. Clients with delirium often exhibit rapid and disorganized speech rather than slowed speech patterns.

B reason: Rapid mood changes. Rapid mood changes are common in delirium. Clients may quickly shift from calm to agitated or from happy to irritable, reflecting the fluctuating nature of their cognitive status.

C reason: Hallucinations. Hallucinations, particularly visual or auditory, are a common symptom of delirium. Clients may see or hear things that are not present, contributing to their confusion and distress.

D reason: Unaltered level of consciousness. Delirium is characterized by altered levels of consciousness, not unaltered. Clients may experience fluctuating alertness, from drowsiness to hyperactivity.

E reason: Restlessness. Restlessness and agitation are hallmark symptoms of delirium. Clients may become physically restless, unable to sit still, and exhibit purposeless movements.

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Correct Answer is C

Explanation

A reason: Administer a sedative medication. While administering a sedative may be necessary to calm the client, it is not the first step. The nurse should initially attempt to de-escalate the situation using non-pharmacological interventions.

B reason: Perform a debriefing with the staff. Debriefing with the staff is important after the situation is under control, but it is not the immediate priority. The focus should first be on addressing the client's behavior and emotions.

C reason: Acknowledge the client's emotions. Acknowledge the client's emotions to de-escalate the situation and help the client feel heard and understood. This can reduce the immediate risk of violence or self-harm.

D reason: Place the client in restraints. Restraints should be used as a last resort when other interventions have failed and there is an immediate risk of harm. The nurse should first try to calm the client through verbal and emotional support.

A. "These clients can receive packages after they are privately inspected by security." B. "These clients cannot be considered for a research study." C. "These clients can vote in local and federal elections." D. "These clients cannot refuse their prescribed antipsychotic medications."

Correct Answer is C

Explanation

A reason: "These clients can receive packages after they are privately inspected by security." While security measures might be in place for the safety of all clients, it does not address a fundamental right of involuntarily admitted clients.

B reason: "These clients cannot be considered for a research study." Involuntarily admitted clients can be considered for research studies, but participation must be voluntary, and informed consent is required.

C reason: "These clients can vote in local and federal elections." Clients who are involuntarily admitted retain their civil rights, including the right to vote in local and federal elections. This statement accurately reflects their rights.

D reason: "These clients cannot refuse their prescribed antipsychotic medications." Involuntarily admitted clients retain the right to refuse medication, except in specific situations where they are deemed a danger to themselves or others, and legal protocols are followed.

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A nurse is assessing a client who has delirium as a result of sepsis. Which of the following manifestations should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is C

Explanation

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