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
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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