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. Delirium often causes disorganized thinking and communication, but speech can be either slow or rapid and incoherent. Slow speech is not a definitive sign of delirium.

B. Rapid mood changes are commonly seen in delirium. Clients may exhibit sudden shifts in mood, such as becoming agitated, anxious, irritable, or euphoric, often without apparent cause.

C. Hallucinations, both visual and auditory, are common manifestations of delirium. Clients may perceive things that are not present, hear voices, or experience other sensory distortions.

D. Delirium typically involves an altered level of consciousness, which can range from hyperalertness to lethargy. An unaltered level of consciousness is not characteristic of delirium.

E. Restlessness, agitation, and an inability to sit still are frequent manifestations of delirium. Clients may exhibit hyperactivity, fidgeting, pacing, or attempting to remove medical devices or clothing.

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Correct Answer is A

Explanation

A. “I check my breasts for lumps every day, but I’m still really scared about getting breast cancer.”: This statement reflects excessive worry about a specific medical condition (breast cancer) despite engaging in frequent checking behaviors. It is consistent with illness anxiety disorder.

B. “I have had several negative pregnancy tests but know they are all wrong.”: This statement suggests a belief that contradicts objective evidence (negative pregnancy tests) and may indicate a somatic symptom disorder or a delusional disorder rather than illness anxiety disorder.

C. “I double-check my pills because I think the pharmacist may be putting poison in them.”: This statement reflects mistrust or paranoia about medications and the intentions of the pharmacist. While it involves health-related concerns, it may be more indicative of paranoid ideation or delusional beliefs.

D. “I feel really nervous when my partner goes to work, and I am home alone during the day.”: This statement describes anxiety related to separation from a partner and being alone, which is not a characteristic feature of illness anxiety disorder. It may be more indicative of generalized anxiety disorder or separation anxiety disorder.

Correct Answer is ["2"]

Explanation

To find out how many tablets the nurse should administer per dose, we need to divide the total daily dose (300 mg) by the dose strength per tablet (50 mg).

300 mg total daily dose / 50 mg per tablet = 6 tablets per day

Since the dose is divided equally every 8 hours, we divide the total daily dose by the number of times it is administered in a day:

6 tablets per day / 3 doses per day = 2 tablets per dose

So, the nurse should administer 2 tablets per dose

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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 on a mental health unit is leading a group therapy session for a group of clients. Which of the following statements should the nurse expect from a client who has illness anxiety disorder?

Correct Answer is A

Explanation

Correct Answer is ["2"]

Explanation

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