A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)

Agitation

Slow, flat speech

Visual hallucinations

Confusion

Rapid mood swings

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.

Choice B rationale:

Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.

Choice C rationale:

Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.

Choice D rationale:

Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.

Choice E rationale:

Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.

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Correct Answer is C

Explanation

Choice A rationale:

Taking a hot bath to relieve muscle spasms might exacerbate symptoms in individuals with multiple sclerosis due to heat sensitivity.

Choice B rationale:

Participating in high-impact exercise daily can be challenging for individuals with multiple sclerosis, who may experience fatigue and mobility issues.

Choice C rationale:

Adequate hydration is essential for individuals with multiple sclerosis to maintain overall health and support neurological function.

Choice D rationale:

Restricting daily intake of dietary fiber is not recommended, as fiber can aid in maintaining bowel regularity for individuals with multiple sclerosis.

A. "I feel guilty that my fellow soldiers died in combat and I survived." B. "I keep having flashbacks about when I was attacked by my neighbor." C. "I prefer to go through the recovery process independently." D. "I think my experience has affected my ability to trust others."

Correct Answer is B

Explanation

Choice A rationale:

Expressing feelings of guilt and survivor's guilt is a common aspect of processing traumatic experiences and can be an important step in healing.

Choice B rationale:

Rationale: This statement indicates that the client is acknowledging and discussing the flashbacks related to the traumatic event. Progression toward positive outcomes in posttraumatic stress disorder (PTSD) often involves recognizing and addressing distressing symptoms.

Choice C rationale:

The preference for independence may indicate resistance to seeking support, which can hinder progress in addressing and managing PTSD symptoms.

Choice D rationale:

Recognizing that the traumatic experience has affected the ability to trust others reflects insight into the impact of the trauma on relationships, which is a step toward positive outcomes.

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A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning teaching for a client who has multiple sclerosis. Which of the following instructions should the nurse plan to include?

Correct Answer is C

Explanation

A nurse is facilitating a group session for clients who have posttraumatic stress disorder. Which of the following client statements indicates progression toward positive outcomes?

Correct Answer is B

Explanation

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