A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?
Gradual onset
Impaired judgment
Difficulty swallowing
Slowed, flat speech
The Correct Answer is B
Choice A reason: Delirium is characterized by an acute onset, typically developing over hours to a few days. It is a sudden change in mental status that differs from conditions like dementia, which have a gradual onset. Therefore, gradual onset is not a characteristic finding of delirium.
Choice B reason: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.
Choice C reason: Difficulty swallowing, or dysphagia, is not typically associated with delirium. Dysphagia is more often related to neurological conditions such as stroke, Parkinson's disease, or other disorders affecting the muscles involved in swallowing. While clients with delirium may have various physical symptoms due to underlying causes, difficulty swallowing is not a direct symptom of delirium itself.
Choice D reason: Slowed, flat speech is not a typical finding in delirium. Clients with delirium may exhibit rapid, incoherent, or disorganized speech due to their altered mental state. Slowed, flat speech is more commonly seen in conditions like depression or certain types of dementia rather than in acute delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Response prevention is a technique often used in the treatment of obsessive-compulsive disorder (OCD). This approach involves preventing the client from engaging in the compulsive behavior they typically perform in response to an anxiety-producing obsession. While effective for OCD, this technique is not typically used for treating specific phobias like the fear of elevators.
Choice B reason: Systematic desensitization is an effective behavioral strategy for decreasing anxiety related to specific phobias. This method involves gradually exposing the client to the feared object or situation—in this case, elevators—in a controlled and progressive manner while teaching relaxation techniques. By slowly and systematically confronting the phobia, the client can learn to reduce their anxiety response over time. This approach helps them manage their fear more effectively and builds their confidence in facing the phobic situation.
Choice C reason: Thought stopping is a cognitive-behavioral technique used to interrupt and prevent distressing thoughts. The client is trained to recognize these thoughts and use a specific action or command, such as saying "Stop" out loud, to halt the negative thought process. While this technique can be helpful for managing anxiety and intrusive thoughts, it is not the primary behavioral strategy for treating specific phobias.
Choice D reason: Flooding, also known as exposure therapy, involves exposing the client to the phobic situation in an intense and prolonged manner until their anxiety diminishes. This approach can be effective but is often overwhelming and can cause significant distress. It requires careful supervision and is not typically the first-line treatment for specific phobias due to the potential for causing trauma or exacerbating the fear.
Correct Answer is B
Explanation
Choice A reason: While this statement might be true, it can come across as dismissive or invalidating the adolescent's feelings. The nurse's goal should be to listen and understand the adolescent's perspective, rather than making assumptions about the parents' intentions.
Choice B reason: This response opens up a conversation about the adolescent's feelings and experiences regarding their relationship with their parents. It shows empathy and a willingness to understand the adolescent's perspective, which can help build trust and rapport. By exploring the relationship, the nurse can gather more information and provide appropriate support and guidance.
Choice C reason: Asking "Why do you think your parents are hard to please?" can come across as confrontational or judgmental. It might make the adolescent feel defensive or misunderstood. The nurse should focus on creating a supportive environment for the adolescent to express their feelings without feeling judged.
Choice D reason: Telling the adolescent that "Things will get better as time goes on" can seem dismissive and may not address the immediate concerns and feelings the adolescent is experiencing. It is important for the nurse to validate the adolescent's feelings and offer support and understanding in the present moment.
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