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.

A. Dissociation B. Rationalization C. Undoing D. Reaction formation

Correct Answer is A

Explanation

A. Dissociation

Dissociation is a defense mechanism where a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with a traumatic or stressful situation. In the context of PTSD, dissociation may manifest as the inability to recall details of the traumatic event or feeling disconnected from reality.

B. Rationalization

Rationalization involves justifying or explaining behaviors, thoughts, or feelings in a rational or logical manner to make them acceptable to oneself or others. It is not typically associated with the inability to recall details of a traumatic event.

C. Undoing

Undoing is a defense mechanism characterized by engaging in acts or behaviors aimed at negating or "undoing" a previous undesirable thought, feeling, or action. It involves trying to make amends for perceived wrongdoings or mistakes, often through symbolic gestures. It is not typically associated with memory impairment related to trauma.

D. Reaction formation

Reaction formation is a defense mechanism where a person behaves in a manner that is opposite to their true feelings or impulses. For example, someone who feels hostility towards another person might display exaggerated friendliness. While reaction formation may be present in individuals with PTSD, it is not directly related to the inability to recall details of a traumatic event.

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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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