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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason:

Word salad.

Word salad refers to a jumble of words and phrases that lack logical coherence, often seen in severe cases of schizophrenia. The speech is typically incomprehensible and does not follow any recognizable pattern. In this case, the client’s response, while unusual, follows a pattern based on sound rather than meaning, which does not fit the definition of word salad.

Choice B Reason:

Loose association.

Loose association involves a series of thoughts that are only loosely connected to each other. This is a common symptom in schizophrenia, where the person’s thoughts may drift from one topic to another with little logical connection. However, the client’s response in this scenario is more structured and based on rhyming, which is characteristic of clang associations rather than loose associations.

Choice C Reason:

Clang association.

Clang association is a type of thought disorder where the person’s speech is governed by the sound of words rather than their meaning. This often results in rhyming or punning speech. The client’s response, “A match is a catch. A catch is a batch. The batch started to hatch,” is a clear example of clang association because the words are linked by their similar sounds rather than their meanings.

Choice D Reason:

Ideas of reference.

Ideas of reference involve the belief that ordinary events, objects, or behaviors of others have particular and unusual significance specifically for the person. This is often seen in paranoid schizophrenia. The client’s response does not indicate that they believe the words have special personal significance; instead, it shows a pattern of rhyming, which is more indicative of clang association.

Correct Answer is ["0.5"]

Explanation

Step 1: Identify the available concentration of fentanyl.

The ampule contains 100 micrograms of fentanyl in 2 mL.

Step 2: Determine the dose required.

The nurse needs to give 25 micrograms of fentanyl.

Step 3: Calculate the volume (mL) needed for the required dose.

Use the formula: (Dose required ÷ Dose available) × Volume of available dose.

Step 4: Substitute the values into the formula.

(25 micrograms ÷ 100 micrograms) × 2 mL

Step 5: Perform the division.

25 micrograms ÷ 100 micrograms = 0.25

Step 6: Perform the multiplication.

0.25 × 2 mL = 0.5 mL

Result: The nurse will give 0.5 mL for the correct dose.

Final Answer: 0.5 mL

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client hears the word “match.” The client replies, “A match is a catch. A catch is a batch. The batch started to hatch.” Which communication pattern does the nurse identify?

Correct Answer is C

Explanation

The nurse must give 25 micrograms of fentanyl IVP X1 dose. Fentanyl is available in an ampule 100 micrograms per 2m How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

Correct Answer is ["0.5"]

Explanation

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