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 C
Explanation
Choice A Reason:
Administer the medication with food.
Administering clonazepam with food can help reduce gastrointestinal discomfort, but it is not the most critical consideration. While it is beneficial to minimize potential side effects like nausea, it does not address the primary safety concerns associated with clonazepam use.
Choice B Reason:
Administer the medication to the client at night to avoid daytime sedation.
Administering clonazepam at night can help avoid daytime sedation, which is a common side effect of benzodiazepines. However, this is not the most critical safety concern. While managing sedation is important, it does not address the potential for more serious interactions and risks.
Choice C Reason:
Encourage the client to avoid drinking alcohol when taking this medication.
This is the correct response. Alcohol can significantly increase the sedative effects of clonazepam, leading to dangerous levels of sedation, respiratory depression, and even death. It is crucial to educate clients about the risks of combining alcohol with benzodiazepines to prevent potentially life-threatening interactions.
Choice D Reason:
Assess for history of smoking.
While assessing for a history of smoking is part of a comprehensive health assessment, it is not the most critical consideration when administering clonazepam. Smoking does not have the same immediate and severe interaction risks with clonazepam as alcohol does.
Correct Answer is D
Explanation
The correct answer is d.
Choice A Reason:
The statement “Bureaucratic” is incorrect. Bureaucratic leadership is characterized by strict adherence to rules and procedures, with decisions made based on established policies. While this style ensures consistency and compliance, it does not typically involve the direct and decisive intervention seen in the scenario described. Bureaucratic leaders focus more on following protocols rather than making quick, authoritative decisions.
Choice B Reason:
The statement “Laissez-Faire” is incorrect. Laissez-Faire leadership is a hands-off approach where leaders provide minimal direction and allow team members to make their own decisions. This style is the opposite of what is demonstrated in the scenario, where the nurse takes immediate control of the situation. Laissez-Faire leaders typically avoid intervening directly and prefer to let issues resolve themselves.
Choice C Reason:
The statement “Democratic” is incorrect. Democratic leadership involves participative decision-making, where leaders seek input and feedback from team members before making decisions. In the scenario, the nurse does not seek input from the group but instead makes a unilateral decision to handle the matter and move on. This approach is not characteristic of democratic leadership, which values collaboration and consensus.
Choice D Reason:
The statement “Autocratic” is correct. Autocratic leadership is characterized by individual control over decisions, with little input from group members. The nurse’s behavior in the scenario—taking charge of the situation and making a quick decision without consulting the group—is indicative of an autocratic leadership style. Autocratic leaders are decisive and often make decisions independently, focusing on efficiency and control.
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