A nurse is caring for a client who is experiencing delirium. Which of the following findings should the nurse expect?

Catatonia

Echopraxia

Agraphia

Illusions

Answer and Explanation

The Correct Answer is D

A. Catatonia. Catatonia involves significant motor disturbances such as rigidity, mutism, or excessive movement, commonly seen in schizophrenia or severe mood disorders. Delirium is characterized by acute confusion, fluctuating attention, and perceptual disturbances rather than motor abnormalities.
B. Echopraxia. Echopraxia is the involuntary repetition of another person’s movements, often linked to schizophrenia and autism spectrum disorders. Delirium primarily presents with disorientation, altered consciousness, and hallucinations rather than repetitive motor behaviors.
C. Agraphia. Agraphia is the loss of the ability to write due to neurological conditions like stroke or dementia. Delirium is an acute and reversible cognitive disturbance that affects attention and perception but does not typically result in isolated language deficits.
D. Illusions. Illusions involve the misinterpretation of real stimuli, such as mistaking a cord for a snake, and are common in delirium. This occurs due to the client's fluctuating mental status, impaired sensory perception, and difficulty distinguishing reality from distorted perceptions.

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Correct Answer is A

Explanation

A. Raises all four side-rails on the client's bed. Raising all four side-rails can create a risk for falls, as it may lead to a false sense of security and prevent the client from being able to exit the bed safely if needed. Additionally, it can increase the risk of entrapment or injury. The recommended practice is to keep two side-rails up while allowing for easy access and mobility for the client.
B. Locks the wheels on the client's bed. Locking the wheels on the client's bed is an appropriate action. This prevents the bed from rolling and helps ensure the client's safety, particularly when they are getting in and out of bed or during care activities.
C. Assists the client to the bathroom every 2 hr. Assisting the client to the bathroom every 2 hours is a reasonable intervention for a client at risk for falls, as it promotes regular toileting and prevents the need for urgent trips to the bathroom that could increase the risk of falling.
D. Clears furniture from the path leading to the bathroom. Clearing furniture from the path leading to the bathroom is a proactive safety measure. This reduces obstacles and hazards, promoting a safer environment for the client and minimizing the risk of falls during ambulation.

A. The client's extremity should be elevated after the cast is applied. B. The client should keep the cast covered until it is dry. C. The client can shower with the cast after 24 hr. D. The client should use a hair dryer on a warm setting for relieve itching inside the cast.

Correct Answer is A

Explanation

A. The client's extremity should be elevated after the cast is applied. Elevating the extremity above heart level for the first 24 to 48 hours reduces swelling and prevents complications such as compartment syndrome. Ice packs can also be applied to minimize edema.
B. The client should keep the cast covered until it is dry. Covering a wet plaster cast can trap moisture and delay drying, increasing the risk of weakening the cast and skin irritation. Plaster casts should be left uncovered to allow proper air drying.
C. The client can shower with the cast after 24 hr. Plaster casts are not waterproof and should be kept dry at all times. If exposed to water, they can lose their shape and strength, potentially leading to improper healing. A plastic covering should be used when bathing.
D. The client should use a hair dryer on a warm setting to relieve itching inside the cast. Direct heat can weaken the plaster and cause burns. Instead, clients should use a cool hair dryer setting or tap lightly on the cast to manage itching without compromising its integrity.

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A nurse is caring for a client who is experiencing delirium. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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