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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Sparse eyelashes are a common physical characteristic of individuals with Down syndrome and do not typically require immediate notification of the provider.
Choice B rationale:
Cracked skin on feet is not uncommon, and while it may need attention, it does not generally require immediate notification of the provider.
Choice C rationale:
Persistent neck pain in a child with Down syndrome could indicate an underlying issue and should be reported for further evaluation.
Choice D rationale:
Hyperflexibility is a common feature of Down syndrome and does not typically require immediate notification of the provider.
Correct Answer is D
Explanation
Choice A rationale:
Hot flashes are not typically associated with postpartum depression; they are more related to hormonal changes.
Choice B rationale:
Intermittent abdominal pain is common after childbirth due to uterine contractions and involution.
Choice C rationale:
Blurred vision is not a typical symptom of postpartum depression.
Choice D rationale:
Feelings of intense guilt are indicative of postpartum depression and require further investigation.
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