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 D

Explanation

A. “I agree with you I'm sure this will never happen again.”: This response dismisses the seriousness of the situation and does not address the potential risk to the child's safety. It's important not to make assumptions about future behavior without further investigation.

B. “This is awful. You should file charges against your partner.”: While it's important to address the safety of the child, suggesting legal action may escalate the situation and could potentially put the child or parent at risk. It's important to handle such situations delicately and considerately.

C. “This is clearly child endangerment. I will have to call the police.”: While the safety of the child is paramount, involving the authorities should be done cautiously and with consideration for the family's dynamics. Calling the police immediately may not always be the most appropriate first step, especially without further assessment or discussion with the parent.

D. “I’d like to know more about what happened. Let’s sit and talk.”: This response is the most appropriate. It demonstrates a non-judgmental and supportive approach while also indicating a commitment to understanding the situation further. Sitting down to talk allows the nurse to gather more information, assess the child's safety, and provide appropriate support and resources to the family.

A. Provide additional attention to the client B. Apply mechanical restraints before administering medication C. Obtain a verbal contract from the client D. Limit staff members who work with the client

Correct Answer is C

Explanation

A. Provide additional attention to the client: While individuals with BPD may crave attention and validation, providing excessive attention can reinforce maladaptive behaviors. Instead, the focus should be on providing consistent and appropriate support while also setting boundaries to encourage healthy coping mechanisms.

B. Apply mechanical restraints before administering medication: Mechanical restraints should only be used as a last resort when less restrictive interventions have failed to ensure the safety of the client and others. Applying restraints before attempting other interventions is not appropriate and may escalate the situation.

C. Obtain a verbal contract from the client: A verbal contract is an agreement between the client and the treatment team regarding safety measures and coping strategies. This intervention involves collaboratively establishing agreements with the client, which can help empower them to take responsibility for their behaviors and engage in treatment planning.

D. Limit staff members who work with the client: Limiting staff members who work with the client may inadvertently isolate the client and hinder the development of therapeutic relationships. Consistency in staffing and a collaborative approach among team members are often more beneficial in providing comprehensive care.

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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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