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 C

Explanation

A. Acute onset of confusion. Dementia is a progressive, chronic condition that develops gradually over time. An acute onset of confusion is more characteristic of delirium, which is a sudden, reversible condition often caused by infections, metabolic imbalances, or medications.
B. Illusions. While individuals with dementia may experience visual misperceptions, true illusions—misinterpretations of real external stimuli—are more commonly associated with delirium or psychiatric disorders. Dementia more often leads to problems with recognition (agnosia) rather than distorted perception.
C. Memory loss that disrupts ADLs. Dementia is characterized by progressive cognitive decline, including memory impairment severe enough to interfere with daily activities such as managing finances, preparing meals, or personal hygiene. As the disease progresses, individuals may struggle with problem-solving, language, and recognizing familiar people or places.
D. Catatonia. Catatonia is a state of motor dysfunction, often seen in severe psychiatric disorders like schizophrenia. While individuals with advanced dementia may become withdrawn or exhibit reduced movement, true catatonia, which involves stupor or repetitive movements, is not a hallmark of dementia.

A. Clear rhinorrhea B. Medications for a cardiac anomaly C. Chemotherapy treatments D. Two diarrhea stools in the last day

Correct Answer is C

Explanation

A. Clear rhinorrhea. Mild respiratory illnesses, such as a common cold with clear nasal discharge, do not contraindicate varicella vaccination. The immunization can still be administered unless the child has a moderate to severe illness with fever.
B. Medications for a cardiac anomaly. Having a congenital heart defect or taking cardiac medications does not typically contraindicate varicella vaccination. However, children on high-dose immunosuppressive therapy for heart conditions may need further evaluation before receiving live vaccines.
C. Chemotherapy treatments. Chemotherapy suppresses the immune system, increasing the risk of severe complications from live vaccines like varicella. Children undergoing chemotherapy should not receive live-virus vaccines until immune function has sufficiently recovered, as determined by a healthcare provider.
D. Two diarrhea stools in the last day. Mild, self-limiting diarrhea does not contraindicate vaccination. Only children with severe acute gastrointestinal illness should have vaccinations postponed until they recover.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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