Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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. Biofeedback B. Acupuncture C. Reiki D. Autogenic training

Correct Answer is A

Explanation

The correct answer is a.

Choice A Reason:

The statement “Biofeedback” is correct. Biofeedback is a technique that uses electronic monitoring devices to help individuals gain control over involuntary bodily functions such as heart rate, muscle tension, and blood pressure. During biofeedback sessions, sensors are attached to the body to measure physiological functions, and the feedback from these sensors helps clients learn to control their physical responses to stress. This method is particularly effective for managing conditions like chronic pain, anxiety, and hypertension.

Choice B Reason:

The statement “Acupuncture” is incorrect. Acupuncture is a traditional Chinese medicine practice that involves inserting thin needles into specific points on the body to balance the flow of energy or qi. While acupuncture can help manage stress and pain, it does not use electronic monitoring devices to provide feedback on physiological functions5. Instead, it relies on the practitioner’s skill and knowledge of acupuncture points and meridians.

Choice C Reason:

The statement “Reiki” is incorrect. Reiki is a form of energy healing that involves the practitioner placing their hands lightly on or just above the client’s body to channel healing energy. Reiki aims to promote relaxation, reduce stress, and support the body’s natural healing processes. However, it does not involve the use of electronic monitoring devices to provide feedback on physiological functions.

Choice D Reason:

The statement “Autogenic training” is incorrect. Autogenic training is a relaxation technique that involves self-suggestion and visualization to induce a state of relaxation and reduce stress. It focuses on creating sensations of warmth and heaviness in different parts of the body through repeated phrases and mental imagery. While effective for stress management, it does not use electronic monitoring devices to provide feedback on physiological functions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 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?

Correct Answer is A

Explanation

The nurse recognizes that a function of the Mental Status Exam is to:

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

Which action should the nurse take prior to educating clients about relaxation techniques?

The nurse understands that whether or not a client experiences a crisis as a result of a stressful situation depends on:

A client is admitted to the Emergency Department (ED) after ingesting a large amount of diazepam. Which medication would the nurse expect the ED physician to order?

A client is having trouble remembering to take his antipsychotic medication, risperidone 3 mg PO, BID. The treatment team at the clinic he attends is considering starting him on risperidone 10 mg IM every 2 weeks. The rationale for this is:

A nurse is caring for a client who has schizophrenia. The client is in the dayroom and shouting at other clients, stating, “Do not eat the food here. The staff is poisoning the food!” The nurse should document that the client is experiencing which type of delusion?

A client with a diagnosis of schizophrenia says to the student nurse, “The mazurkas are coming. The mazurkas are coming.” The client’s use of the word ‘mazurka’ is most likely a/an: