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 B

Explanation

A. A client who has a new diagnosis of major depressive disorder: While major depressive disorder can significantly impact functioning and may require treatment, it typically does not meet the criteria for ACT, which is primarily designed for individuals with severe and persistent mental illness.

B. A client who has repeated acute care admissions due to schizophrenia: Repeated acute care admissions due to schizophrenia suggest significant challenges in managing the illness and maintaining stability in the community. This client may benefit from the intensive support and comprehensive services provided by ACT to prevent future hospitalizations and promote community integration.

C. A client who has requested family therapy following the death of a family member: Family therapy may be an appropriate intervention for supporting this client's grieving process and addressing family dynamics. However, it does not necessarily indicate the need for ACT, which is focused on individuals with severe and persistent mental illness.

D. A client who has physical injuries following an incident of partner violence: While this client may require support and interventions to address the effects of partner violence, it does not specifically indicate the need for ACT unless there are underlying severe and persistent mental health issues contributing to the situation.

A. “I place my child in time-out for 15 minutes when they misbehave.” B. "I send my child to their room for the time-out period." C. “I make use of time-out after gang three warnings." D. “I use a kitchen timer to mark the end of the time-out period.”

Correct Answer is D

Explanation

A. “I place my child in time-out for 15 minutes when they misbehave.”: This statement indicates a clear understanding of time-out as a form of discipline. Time-out is typically implemented for a short duration, often recommended to be around one minute per year of the child's age (e.g., 3 minutes for a 3-year-old). Placing the child in time-out for 15 minutes aligns with this understanding.

B. "I send my child to their room for the time-out period.": Sending a child to their room as a time-out may not be as effective, as the child may have access to toys, books, or other distractions in their room. Time-out is more effective when the child is placed in a designated, neutral area with minimal stimulation.

C. “I make use of time-out after giving three warnings.": While giving warnings before implementing time-out can be part of a structured discipline approach, the number of warnings may vary depending on the situation and the child's behavior. There is no universally recommended number of warnings before using time-out.

D. “I use a kitchen timer to mark the end of the time-out period.”: Using a kitchen timer to mark the end of the time-out period is a practical strategy that helps ensure consistency and fairness in the duration of time-out. It indicates an understanding of the need to adhere to a specific time frame for time-out.Using a timer helps ensure that the time-out duration is consistent and allows the child to know when the consequence ends.

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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.)

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Naxlex Comprehensive Predictor Exams

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