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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This question helps the nurse to evaluate the client's personal coping skills and identify their strengths and weaknesses. Asking about the impact of the situation, the current feelings, or the future outlook are not directly related to coping skills, although they might provide some useful information.
Correct Answer is B
Explanation
The nurse's priority is to ensure that the child is safe and protected from further harm. A spiral fracture is a type of fracture that occurs when a bone is twisted, and it is often associated with child abuse. The nurse should assess if there are any other signs of abuse, such as bruises, burns, or cuts, and if there are any threats to the child's well-being at home or elsewhere. The nurse should also provide emotional support and comfort to thechild. The other options are important steps to take, but they are not as urgent as ensuring safety.
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