A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F).

A client attempts to climb out of bed and repeatedly states she must get home.

A client refuses to get out of bed and has no motivation to attend to daily hygiene.

A client wants to know the current time while there is a clock on the wall.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B.

Choice A rationale:

A client requesting extra blankets due to a room temperature discrepancy is not indicative of delirium. This behavior may simply stem from feeling cold, which is a logical response to a temperature below the client's comfort level.

Choice B rationale:

A client attempting to climb out of bed and repeatedly stating a need to get home is a manifestation of delirium. Delirium is characterized by sudden disturbances in consciousness and cognitive function, leading to confusion and altered perception. The client's behavior suggests a disoriented state and a distorted perception of reality.

Choice C rationale:

A client refusing to get out of bed and lacking motivation for daily hygiene might not necessarily indicate delirium. These symptoms could be related to other factors, such as depression or physical discomfort, which are not specific to delirium.

Choice D rationale:

A client wanting to know the current time when there is a visible clock on the wall doesn't indicate delirium. It might just reflect the client's desire to know the time, which is a common behavior and doesn't directly relate to cognitive disturbances associated with delirium.

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Correct Answer is D

Explanation

The correct answer is choice D: "If suspicion of abuse exists, then reporting is mandatory."

Choice A rationale:

If the potential abuser commits to stopping the abuse, healthcare workers are not required to report it. Rationale: This statement is incorrect. Healthcare workers are mandated reporters, and their primary responsibility is to protect the safety and well-being of the child. Regardless of whether the potential abuser commits to stopping the abuse, suspicion of abuse requires reporting.

Choice B rationale:

Evidence must exist before reporting. Rationale: This statement is incorrect. While concrete evidence can strengthen a case, it is not a prerequisite for reporting suspected child abuse. Reporting is based on reasonable suspicion, not proof. Healthcare workers should err on the side of caution and report any concerns.

Choice C rationale:

I don't want to defame someone if the report is false. Rationale: This statement is incorrect. Reporting suspected child abuse is not about defaming someone, but rather about ensuring the safety of the child. Reporting is a part of the legal and ethical obligations of healthcare workers to protect vulnerable individuals.

Choice D rationale:

If suspicion of abuse exists, then reporting is mandatory. Rationale: This statement is correct. Healthcare workers are mandated reporters and have a duty to report suspected child abuse to appropriate authorities. Reporting is necessary when there is reasonable suspicion, even if definitive evidence is not yet present.

A. "You need to tell the voices to leave you alone.” B. "You need to understand that there are no voices.” C. "What are the voices telling you to do?” D. "Why do you think you are hearing the voices?”

Correct Answer is C

Explanation

Choice A rationale:

Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.

Choice B rationale:

Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.

Choice C rationale:

This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.

Choice D rationale:

Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.

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A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates that the newly licensed nurse has the correct information about child abuse?

Correct Answer is D

Explanation

A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse in the Emergency Department is caring for a client with symptoms of depression and admits to thoughts of self-harm with a plan. The client has a history of borderline personality disorder, depression, and substance abuse. Which of the following is the priority action by the nurse?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?

A nurse in the acute mental health unit is admitting a new client with an eating disorder. The nurse is aware that which of the following are considered comorbidities of eating disorders? (Select all that apply.)