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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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