A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?

Echopraxia

Aphasia

Acute onset of confusion

Inability to read

Answer and Explanation

The Correct Answer is C

Choice A reason: Echopraxia, mimicking movements, is linked to psychiatric conditions like schizophrenia, not delirium. Delirium features disordered cognition from physiological causes (e.g., infection), not motor imitation. Scientifically, this lacks relevance to delirium’s acute, fluctuating mental state driven by underlying medical issues.

Choice B reason: Aphasia, a language deficit, stems from brain damage (e.g., stroke), not delirium’s reversible cognitive disruption. Delirium affects attention and awareness, not specific linguistic skills. Scientifically, this is distinct from delirium’s diffuse, temporary confusion tied to systemic or metabolic disturbances.

Choice C reason: Acute onset of confusion defines delirium, a sudden cognitive decline from causes like infection or drugs. It’s reversible with treatment, featuring inattention and disorientation, aligning with scientific criteria as a hallmark symptom distinguishing it from chronic conditions like dementia.

Choice D reason: Inability to read relates to literacy or focal brain injury, not delirium. Delirium impairs global cognition—attention and memory—not specific skills like reading unless confusion interferes indirectly. Scientifically, this isn’t a core feature, as delirium’s impact is broader and transient.

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Correct Answer is D

Explanation

Choice A reason: Dry mucous membranes signal dehydration, not hyperkalemia directly. High potassium affects cardiac and nerve function, not mucosal hydration status in renal failure.

Choice B reason: Hyperactive reflexes occur in hypocalcemia, not hyperkalemia. Excess potassium depresses nerve and muscle activity, often reducing reflexes instead of enhancing them.

Choice C reason: Trousseau’s sign indicates hypocalcemia, with carpal spasm from cuff pressure. Hyperkalemia in renal failure doesn’t trigger this; it’s a calcium issue.

Choice D reason: Irregular heart rate, like bradycardia or arrhythmias, stems from hyperkalemia’s effect on cardiac conduction. In renal failure, potassium excess disrupts rhythms critically.

A. Recurring urinary tract infections B. A recent move to a new city C. Report of feeling depressed D. Lack of nutritional knowledge

Correct Answer is B

Explanation

Choice A reason: Recurring UTIs are physical health issues, not external stressors. They’re internal consequences, not environmental triggers, though stress may exacerbate them indirectly.

Choice B reason: A recent move is an external stressor, disrupting routine and social ties. It’s an environmental change, directly causing stress per psychological models.

Choice C reason: Feeling depressed is an internal emotional response, not an external stressor. It’s a symptom, not the originating environmental or situational cause.

Choice D reason: Nutritional knowledge lack is internal, a cognitive deficit. It’s not an external event or pressure, unlike a move’s tangible stress impact.

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A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is in renal failure. Which of the following findings should the nurse identify as a manifestation of hyperkalemia?

Correct Answer is D

Explanation

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

Correct Answer is B

Explanation

A nurse is caring for a client who has lung cancer. The client tells the nurse they do not want to be resuscitated in the event of a cardiac arrest. Which of the following statements should the nurse make?

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child’s school-age brother should the nurse expect?

A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?