A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?

The client has a flat affect.

The client's manifestations developed suddenly.

The client's speech is slow and repetitious.

The client is unable to recognize objects.

Answer and Explanation

The Correct Answer is B

Delirium is an acute confusional state that can have various causes, such as infection, medication, or metabolic imbalance. It is characterized by a sudden onset of altered mental status, fluctuating levels of consciousness, disorientation, and perceptual disturbances.

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Correct Answer is D

Explanation

Referring the client to a self-help group, such as Alcoholics Anonymous (AA), is an effective strategy to promote sobriety and prevent relapse after discharge. Self-help groups provide peer support, education, and coping skills for clients who have alcohol use disorder. Systematic desensitization is a behavioral therapy technique that is used to treat phobias, not alcohol use disorder. Contacting a close relative of the client may be helpful, but it is not a recommendation that the nurse can make without the client's consent and involvement. Buprenorphine is a medication that is used to treat opioid use disorder, not alcohol use disorder.

A. Give the client atropine 30 min before the procedure. B. Assist the client to ambulate for the first time following the procedure. C. Witness the client's signature on the consent for the procedure. D. Check the client's condition after the procedure.

Correct Answer is B

Explanation

A: Giving the client atropine 30 min before the procedure is a task that requires professional nursing knowledge and skill to assess the medication's necessity and potential effects, thus it cannot be delegated to an assistive personnel.
B: Assisting with ambulation is a task that can be safely delegated to an assistive personnel, as it does not require the professional judgment or skill of a nurse. The assistive personnel can help maintain the client's safety while walking after the procedure.
C: Witnessing a client's signature on the consent for the procedure is a legal responsibility and requires an understanding of the procedure's risks and benefits, which is beyond the scope of assistive personnel's responsibilities.
D: Checking the client's condition after the procedure involves assessment and interpretation of clinical data, which are responsibilities of the nurse and cannot be delegated to an assistive personnel.

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A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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