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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 ["B","D","E"]

Explanation

Choice A Reason:

The statement “They do not need to report the use of herbal therapies to the provider” is incorrect. It is crucial for clients to inform their healthcare providers about any herbal therapies they are using. This is because herbal therapies can interact with prescription medications, potentially causing adverse effects or reducing the efficacy of the medications. Healthcare providers need to be aware of all substances a patient is taking to provide safe and effective care.

Choice B Reason:

The statement “Herbal therapies also have side effects and may interact with other medications being taken” is correct. Herbal therapies, despite being natural, can have potent effects on the body and may cause side effects. Additionally, they can interact with other medications, leading to potentially harmful interactions. For example, St. John’s wort can interact with antidepressants, and ginkgo biloba can affect blood clotting. Therefore, it is essential to consider these interactions when using herbal therapies.

Choice C Reason:

The statement “They need to stay away from all herbal therapies” is incorrect. While it is important to be cautious, it is not necessary to avoid all herbal therapies. Many herbal therapies can be beneficial when used appropriately and under the guidance of a healthcare provider. The key is to ensure that the herbal products are safe, effective, and do not interact negatively with other medications the client may be taking.

Choice D Reason:

The statement “Herbal therapies should be purchased from reliable manufacturers with a history of quality control of their product” is correct. The quality of herbal products can vary significantly between manufacturers. Choosing products from reputable manufacturers ensures that the products have been tested for purity, potency, and safety. Reliable manufacturers follow good manufacturing practices and have stringent quality control measures in place, reducing the risk of contamination and ensuring the product’s efficacy.

Choice E Reason:

The statement “They should always inform healthcare providers of the use of herbs” is correct. It is essential for clients to inform their healthcare providers about any herbal therapies they are using. This information helps healthcare providers to monitor for potential interactions and side effects, adjust medication dosages if necessary, and provide comprehensive care. Open communication between clients and healthcare providers is crucial for ensuring safe and effective treatment plans.

A. Restating B. Giving advice C. Maintaining neutral responses D. Asking the client, “Why?” E. Listening

Correct Answer is ["A","C","E"]

Explanation

Choice A Reason:

Restating involves repeating what the client has said in order to show understanding and to encourage them to continue talking. This technique helps to clarify the client’s thoughts and feelings, ensuring that the nurse accurately understands the client’s message. It also demonstrates active listening and empathy, which are crucial components of therapeutic communication.

Choice B Reason:

Giving advice is generally considered a non-therapeutic communication technique. It can imply that the nurse knows best and can undermine the client’s autonomy and decision-making abilities. Instead of giving advice, therapeutic communication focuses on helping clients explore their own thoughts and feelings to arrive at their own conclusions and solutions.

Choice C Reason:

Maintaining neutral responses involves responding to the client in a way that does not convey judgment or bias. This technique helps to create a safe and supportive environment where the client feels comfortable sharing their thoughts and feelings. Neutral responses can include nodding, making non-committal sounds like “mm-hmm,” and using phrases like “I see” or “Tell me more”.

Choice D Reason:

Asking the client “Why?” can be perceived as confrontational or judgmental, which can hinder open communication. It may make the client feel defensive or uncomfortable. Instead, therapeutic communication techniques involve asking open-ended questions that encourage the client to express themselves without feeling judged.

Choice E Reason:

Listening is one of the most fundamental therapeutic communication techniques. It involves giving the client your full attention, showing interest in what they are saying, and responding appropriately to their concerns. Active listening helps to build trust and rapport, making the client feel heard and understood.

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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

During a routine health examination, the client tells the nurse about using a variety of herbal therapies for health maintenance. When discussing the use of herbs, the nurse cautions the client that: (SELECT ALL THAT APPLY)

Correct Answer is ["B","D","E"]

Explanation

A nurse working on a mental health unit reviews therapeutic and non-therapeutic communication techniques with a student nurse. Which of the following are therapeutic communication techniques? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","E"]

Explanation

A client is diagnosed with schizophrenia. The nurse would interpret which behavior as apathy? The client is:

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A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses to stress?

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?

When placing an agitated client in restraints, the nurse understands that which of the following must occur?

Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately?

A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to: