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 B

Explanation

The correct answer is choice B. "It sounds like you're having a difficult time."

Choice A rationale:

"How long has this been going on?" This question focuses on the duration of the client's symptoms, which might not be the most appropriate response at this point. The client's immediate emotional state and distress should be acknowledged before delving into the duration of the issue.

Choice B rationale:

"It sounds like you're having a difficult time." This response demonstrates empathy and understanding towards the client's emotional state. It acknowledges the client's feelings without making assumptions or probing for specific details. It provides a supportive environment for the client to open up further.

Choice C rationale:

"Have you talked to your parents about this yet?" This question assumes that the client's parents are a source of support and that the client has not yet spoken to them about their feelings. It also directs the conversation towards external parties instead of focusing on the client's immediate emotions.

Choice D rationale:

"Why do you think you are so anxious?" This question might come across as confrontational or demanding, potentially making the client defensive. It could hinder open communication and create a barrier between the nurse and the client.

A. "You will need to take this medication on an empty stomach.” B. "You will need to consume a low-salt diet while on this medication.” C. "You will need your blood levels drawn weekly during the first month.” D. "You will need to stop this medication if you develop severe diarrhea.”

Correct Answer is C

Explanation

Choice A rationale:

Ingesting lithium (Eskalith) on an empty stomach can lead to gastrointestinal upset. Therefore, clients are generally advised to take this medication with food or milk to minimize these side effects. This choice is incorrect.

Choice B rationale:

While sodium intake can impact lithium levels, clients are usually advised to maintain a consistent, moderate sodium intake rather than adopting a low-salt diet. Extreme dietary changes can affect lithium levels and potentially lead to toxicity, making this choice inaccurate.

Choice C rationale:

Monitoring blood levels of lithium is crucial to ensure therapeutic effectiveness and prevent toxicity. During the initiation phase, frequent monitoring, typically weekly, is necessary to establish the appropriate dosage for each individual. Lithium has a narrow therapeutic range, and blood levels need to be closely regulated.

Choice D rationale:

Discontinuing lithium abruptly can lead to worsened bipolar symptoms. Diarrhea can contribute to dehydration and electrolyte imbalances, potentially impacting lithium levels, but stopping the medication is not the initial action to take. Adjustments in dosage or management strategies are usually explored before considering discontinuation.

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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 taking care of an adult client who is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is preparing to teach a client about the prescription of lithium (Eskalith) for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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