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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 ["125"]

Explanation

To calculate the infusion rate in drops per minute:

Identify the total volume to be infused: 125 mL
Identify the total time for infusion: 1 hour (which is 60 minutes)
Identify the drop factor: 60 gtts/mL

Step 1: Calculate the infusion rate in mL per minute.

Volume (mL) ÷ Time (minutes)
125 mL ÷ 60 minutes = 2.0833 mL per minute

Step 2: Calculate the infusion rate in drops per minute.

Infusion rate (mL per minute) × Drop factor (gtts/mL)
2.0833 mL per minute × 60 gtts/mL = 125 gtts per minute

The drug will infuse at 125 drops per minute.

A. Hypertension B. Tinnitus C. Metallic taste D. Dizziness

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.

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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

An IV infusion of 125 mL of a GI prokinetic agent is ordered to be given over 1 hour. The nurse will use a microdrip infusion set (60 gtts/mL). How many drops per minute will the drug infuse at the proper rate? Use a preceding zero if necessary. Do not use trailing zeros.

Correct Answer is ["125"]

Explanation

The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?

Correct Answer is D

Explanation

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