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 ["5"]
Explanation
Step-by-Step Calculation
Step 1: Identify the volume of one container in milliliters.
- 1 ounce = 29.5735 mL
- 6 ounces = 6 × 29.5735 mL = 177.441 mL
Step 2: Determine the total volume needed.
- Total volume needed = 850 mL
Step 3: Calculate the number of containers required.
- Number of containers = Total volume needed ÷ Volume of one container
- Number of containers = 850 mL ÷ 177.441 mL
Step 4: Perform the division.
- 850 mL ÷ 177.441 mL ≈ 4.79
Step 5: Round to the nearest whole number.
- 4.79 rounded to the nearest whole number = 5
Result: The minimum number of containers of juice needed is 5.
Final Answer: 5 containers
Correct Answer is C
Explanation
Choice A Reason: Have a poor prognosis
A poor prognosis in schizophrenia is typically associated with persistent and severe symptoms, lack of response to treatment, and significant functional impairment. While the client’s statement about hearing voices is concerning, it does not necessarily indicate a poor prognosis on its own. Prognosis in schizophrenia is multifactorial and depends on various factors, including the duration of untreated psychosis, adherence to treatment, and the presence of supportive social networks.
Choice B Reason: Are not improving and may be getting worse
This choice suggests that the client’s condition is deteriorating. While the presence of hallucinations can indicate a lack of improvement, it is important to consider the context. The client’s ability to question the hallucination and seek reassurance from the nurse suggests a level of insight that is often associated with better outcomes. Insight into one’s condition is a positive prognostic factor in schizophrenia.
Choice C Reason: Are questioning the hallucination and want reassurance from the nurse
This is the correct answer. The client’s question indicates that they are aware that the voices might not be real and are seeking reassurance from the nurse. This level of insight is crucial in managing schizophrenia, as it can lead to better adherence to treatment and improved outcomes. Insight into the nature of hallucinations and delusions is often a sign of a more favorable prognosis.
Choice D Reason: Will begin to enter the manic phase of their illness
Mania is characterized by elevated mood, increased activity, and other symptoms such as decreased need for sleep and grandiosity. It is more commonly associated with bipolar disorder than schizophrenia. The client’s statement about hearing voices predicting their death does not align with the typical presentation of mania. Therefore, this choice is not applicable in this context.
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