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 A
Explanation
Choice A Reason:
This will help with medication compliance.
This is the correct response. Long-acting injectable (LAI) antipsychotics like risperidone IM are often used to improve medication compliance in patients who have difficulty remembering to take their oral medications regularly. By administering the medication every two weeks, the treatment team can ensure that the client receives a consistent dose, reducing the risk of relapse due to missed doses. This approach is particularly beneficial for clients with schizophrenia, as consistent medication adherence is crucial for managing symptoms and preventing hospitalizations.
Choice B Reason:
It will help him remember to take his medication.
While this statement is related to medication compliance, it is not entirely accurate. The purpose of switching to an injectable form is to eliminate the need for the client to remember to take daily doses. Instead, the healthcare provider administers the medication at regular intervals, ensuring adherence without relying on the client’s memory.
Choice C Reason:
This has a faster onset of action.
This statement is incorrect. The onset of action for long-acting injectable risperidone is not necessarily faster than the oral form. In fact, LAIs are designed to release the medication slowly over time to maintain stable blood levels. The primary advantage of LAIs is improved adherence, not a faster onset of action.
Choice D Reason:
This new medication is stronger and will clear his symptoms faster.
This statement is also incorrect. The strength of the medication and the speed at which it clears symptoms are not the primary reasons for switching to an injectable form. The goal is to ensure consistent medication levels and improve adherence, not to increase the potency or speed of symptom relief.
Correct Answer is A
Explanation
Choice A Reason:
Seclusion is used in psychiatric settings primarily to manage patients who are exhibiting aggressive or severely disturbed behavior. The reduced sensory input in a seclusion room helps the patient to regain control over their emotions and behavior by minimizing external stimuli that could exacerbate their condition. This controlled environment can be crucial in preventing harm to the patient and others, and it allows the patient to calm down in a safe space. The goal is to provide a therapeutic setting that aids in the patient’s recovery and stabilization.
Choice B Reason:
While communication is an essential part of psychiatric care, seclusion is not intended to encourage interaction with others. In fact, seclusion is used when a patient needs to be isolated to prevent harm to themselves or others. Encouraging communication is more appropriate in other therapeutic settings where the patient is stable and can engage safely with others. Therefore, this statement does not accurately explain the purpose of seclusion.
Choice C Reason:
Forcing clients to be responsible for themselves is not the primary goal of seclusion. Seclusion is a measure taken to ensure safety and to help the patient regain control over their behavior in a controlled environment. Responsibility and self-management are important aspects of psychiatric treatment, but they are typically addressed through other therapeutic interventions and not through seclusion. Thus, this statement is not an accurate explanation of the use of seclusion.
Choice D Reason:
Managing the unit with fewer staff is not a valid reason for using seclusion. The primary purpose of seclusion is to ensure the safety of the patient and others, not to reduce staffing needs. In fact, the use of seclusion requires careful monitoring and adherence to strict protocols, which can actually increase the need for staff attention. Therefore, this statement does not correctly explain the rationale behind the use of seclusion.
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