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 B
Explanation
Choice A rationale:
Assigning an Apgar score is important, but drying the newborn and promoting warmth are immediate priorities.
Choice B rationale:
Drying the newborn and providing warmth help prevent heat loss and maintain the newborn's body temperature, which is essential for their well-being.
Choice C rationale:
Weighing the newborn is important, but maintaining their body temperature takes precedence immediately after birth.
Choice D rationale:
Placing an identification bracelet on the newborn is important for proper identification, but ensuring the newborn's immediate well-being and comfort is the priority.
Correct Answer is C
Explanation
Choice A rationale:
Scheduling appointments earlier in the day accommodates the client's potential "on" periods when Parkinson's symptoms are better controlled.
Choice B rationale:
Looking down at the feet while walking is a technique that can help improve gait and stability, as Parkinson's disease often affects balance.
Choice C rationale:
Thicker liquids are less likely to cause aspiration in individuals with Parkinson's disease, as they can have difficulty coordinating the muscles needed for swallowing.
Choice D rationale:
Constipation is a common issue in Parkinson's disease due to decreased gastrointestinal motility. However, focusing on dietary fiber and fluid intake is preferred before considering laxatives.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.