A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)
Clear and organized speech
Increased attention and focus
Fluctuating levels of consciousness
Stable and consistent cognitive function
Agitation and aggression
Correct Answer : C,E
The correct answer is c, e.
Choice A Reason:
The statement “Clear and organized speech” is incorrect. Clients with delirium often exhibit disorganized thinking and speech. Their speech may be rambling, irrelevant, or incoherent, reflecting their fluctuating mental state. Clear and organized speech is more characteristic of a person without cognitive impairment or with stable cognitive function.
Choice B Reason:
The statement “Increased attention and focus” is incorrect. Delirium is characterized by a disturbance in attention and awareness. Clients with delirium typically have difficulty sustaining or shifting attention, which is a key diagnostic criterion. Increased attention and focus are not consistent with the presentation of delirium.
Choice C Reason:
The statement “Fluctuating levels of consciousness” is correct. One of the hallmark features of delirium is the fluctuation in the level of consciousness throughout the day3. Clients may experience periods of lucidity interspersed with confusion and disorientation. This fluctuation is a critical diagnostic indicator of delirium.
Choice D Reason:
The statement “Stable and consistent cognitive function” is incorrect. Delirium is marked by an acute change in cognitive function, which is neither stable nor consistent. Cognitive functions such as memory, orientation, and language are typically impaired and fluctuate over time. Stable cognitive function would not support a diagnosis of delirium.
Choice E Reason:
The statement “Agitation and aggression” is correct. Clients with delirium often exhibit behavioral disturbances, including agitation and aggression. These symptoms can result from the confusion and disorientation experienced during delirium. Recognizing these behavioral changes is important for the diagnosis and management of delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Hypertension.
Hypertension, or high blood pressure, is not a common side effect of lorazepam. Lorazepam is a benzodiazepine, which typically causes sedation and relaxation of muscles, leading to a decrease in blood pressure rather than an increase. Therefore, hypertension is not an expected side effect of this medication.
Choice B Reason:
Tinnitus.
Tinnitus, or ringing in the ears, is also not commonly associated with lorazepam use. While tinnitus can be a side effect of various medications, it is not typically linked to benzodiazepines like lorazepam. Therefore, it is not an expected side effect for clients taking this medication.
Choice C Reason:
Metallic taste.
A metallic taste is not a common side effect of lorazepam. This side effect is more often associated with other medications, such as certain antibiotics or chemotherapy drugs. Lorazepam’s side effects are more related to its sedative properties.
Choice D Reason:
Dizziness.
Dizziness is a common side effect of lorazepam. As a central nervous system depressant, lorazepam can cause drowsiness, dizziness, and lightheadedness. Clients should be advised to avoid activities that require alertness, such as driving, until they know how the medication affects them.
Correct Answer is C
Explanation
Choice A Reason:
Labeling mild anxiety as pathologic and suggesting that it warrants postponing the test is not accurate. Mild anxiety is a normal response to stress and can actually be beneficial in certain situations. It helps to increase alertness and focus, which can improve performance on tasks such as taking a test. Pathologic anxiety, on the other hand, is excessive and persistent, interfering with daily functioning and requiring clinical intervention.
Choice B Reason:
The idea that mild anxiety may be transferred to classmates and result in generalized anxiety disorder is not supported by evidence. Anxiety is a personal experience and while it can be influenced by the environment, it is not something that can be directly transferred from one person to another. Generalized anxiety disorder is a chronic condition characterized by excessive worry about various aspects of life, and it develops due to a combination of genetic, environmental, and psychological factors.
Choice C Reason:
While severe anxiety can interfere with cognitive ability, mild anxiety typically does not. In fact, mild anxiety can enhance cognitive performance by increasing alertness and focus. It is only when anxiety becomes overwhelming that it starts to impair cognitive functions such as memory, attention, and problem-solving.
Choice D Reason:
Mild anxiety is conducive to concentration and problem-solving. This level of anxiety can act as a motivator, helping individuals to focus better and perform tasks more efficiently. The Yerkes-Dodson law suggests that there is an optimal level of arousal (including anxiety) that enhances performance. Too little arousal can lead to underperformance, while too much can cause performance to deteriorate.
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