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 B

Explanation

A reason: Flight of ideas. Flight of ideas is characterized by rapid shifts from one topic to another, often with a logical connection between the topics. The client's statement does not exhibit this pattern and is more disorganized.

B reason: Word salad. Word salad refers to a jumble of words and phrases that are incoherent and lack meaningful connections. The client's statement, "Walk tall broom short dog bell," fits this description, as it is a nonsensical combination of words.

C reason: Neologisms. Neologisms are newly created words that have meaning only to the person who uses them. The client's statement does not include any new or invented words, making this choice inappropriate.

D reason: Clang associations. Clang associations involve the use of words based on their sound rather than their meaning, often rhyming or having a similar beginning sound. The client's statement does not exhibit this pattern.

A. Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia. B. Screening college students who demonstrate manifestations of depressive disorder. C. Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments. D. Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease.

Correct Answer is B

Explanation

A reason: Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia. This action represents tertiary prevention, as it involves managing long-term symptoms and complications of an existing condition (tardive dyskinesia) in clients with schizophrenia.

B reason: Screening college students who demonstrate manifestations of depressive disorder. Screening for depressive disorders is a form of secondary prevention. It aims to identify and treat mental health conditions early before they become more severe, thus preventing further complications.

C reason: Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments. This action is an example of tertiary prevention, focusing on improving care and support for clients with existing cognitive impairments, rather than preventing the onset or progression of the condition.

D reason: Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease. This action represents tertiary prevention, as it aims to help individuals cope with the stress and challenges of caregiving for relatives with Alzheimer's disease, rather than preventing the condition itself.

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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

A nurse in an acute care facility is assessing a client who has schizophrenia. The client states, "Walk tall broom short dog bell." The nurse should document the client's speech as which of the following speech patterns?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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