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 D

Explanation

A reason: Urinary retention. Urinary retention can occur with these medications, particularly with opioids like hydromorphone, but it is not typically an immediate priority compared to respiratory depression.

B reason: Blurred vision. Blurred vision can be a side effect of medications, but it is not as immediately critical as respiratory function.

C reason: Headache. A headache, while uncomfortable, is not as urgent as respiratory issues when managing clients on these medications.

D reason: Bradypnea. Bradypnea, or slowed breathing, is a serious and potentially life-threatening side effect of both diazepam and hydromorphone. It indicates respiratory depression, which requires immediate intervention to ensure the client's safety.

A. Lack of eye contact. B. Inability to play quietly. C. Constant spinning of a toy. D. Withdrawal from physical contact. E. Repeated voicing in clothes.

Correct Answer is ["A","C","D"]

Explanation

A reason: Lack of eye contact. Children with autism spectrum disorder (ASD) often exhibit reduced or lack of eye contact, which can be a key indicator of social communication difficulties associated with ASD.

B reason: Inability to play quietly. While some children with autism might exhibit hyperactive behavior, an inability to play quietly is not a specific characteristic of ASD. It can be seen in various conditions, including attention deficit hyperactivity disorder (ADHD).

C reason: Constant spinning of a toy. Repetitive behaviors, such as spinning objects, are common in children with ASD. These behaviors provide sensory input and can be calming for the child.

D reason: Withdrawal from physical contact. Children with ASD often withdraw from physical contact due to sensory sensitivities. They might find certain touches uncomfortable or overwhelming.

E reason: Repeated voicing in clothes. Repeating phrases or sounds, known as echolalia, is common in ASD, but "repeated voicing in clothes" does not accurately describe this behavior. It seems like a typographical error.

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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 is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

Correct Answer is D

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Correct Answer is ["A","C","D"]

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