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 C

Explanation

Choice A rationale:

While wanting to go home to be with loved ones can be a sign of distress, it doesn't necessarily indicate an immediate risk of suicide. Many individuals express a desire to be with family when feeling down, and this statement alone is not a definitive indicator of suicide risk.

Choice B rationale:

Engaging in social activities like playing basketball with others is generally a positive sign, as it indicates some level of interaction and engagement. This choice is less likely to indicate an immediate suicide risk.

Choice C rationale:

The client demonstrating increased impulsive behaviors is a concerning sign. Rapid and impulsive actions can potentially lead to self-harm or dangerous situations. Increased impulsivity can indicate a lack of consideration for consequences, which may elevate the risk of suicidal behaviors.

Choice D rationale:

Identifying with problems expressed by other clients is not a specific indicator of suicide risk. While it may suggest empathy and shared experiences, it doesn't directly address the immediate risk factors related to the client's bipolar disorder.

A. Services aimed at reducing the residual defects that are associated with severe and persistent mental illness. B. Interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness. C. Services aimed at reducing the incidence of mental disorders within the population. D. Accomplished through early identification of problems and prompt initiation of effective treatment.

Correct Answer is C

Explanation

Choice A rationale:

This choice describes tertiary prevention, which focuses on minimizing the consequences of an existing disorder or preventing further deterioration. It is not directly related to primary prevention, which addresses the prevention of the onset of disorders.

Choice B rationale:

This choice corresponds to secondary prevention, which involves early intervention to minimize the impact of an illness that has already begun. It aims to reduce the prevalence and duration of the illness but is not the primary focus of primary prevention.

Choice C rationale:

The correct choice. Primary prevention focuses on reducing the incidence of mental disorders within the population. It involves strategies that target the entire population or specific high-risk groups to prevent the initial development of mental health issues. These strategies may include public health campaigns, education, and interventions to promote mental well-being and resilience.

Choice D rationale:

This choice describes the process of early identification and initiation of treatment, which is a component of secondary prevention. It aims to prevent the progression of existing problems rather than preventing the initial development of mental disorders.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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