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 B

Explanation

Choice A reason: Hand tremors are not a primary symptom of anaphylaxis, which epinephrine treats. Tremors may occur from anxiety or other conditions, but epinephrine’s beta-adrenergic effects target airway dilation and vasoconstriction, not neurologic stabilization, making this unrelated to its acute therapeutic purpose.

Choice B reason: Shortness of breath, common in anaphylaxis, results from bronchoconstriction and airway swelling. Epinephrine acts on beta-2 receptors to relax bronchial smooth muscle, reversing dyspnea. This aligns with its primary use in allergic reactions, restoring oxygenation by counteracting histamine-induced distress.

Choice C reason: Nausea may accompany anaphylaxis due to systemic histamine release, but epinephrine does not directly treat it. Its focus is on reversing airway and vascular collapse, not gastrointestinal symptoms, which are secondary, making this an incidental, not primary, target of action.

Choice D reason: Hyperglycemia is not an anaphylactic symptom; epinephrine may raise blood sugar as a side effect via glycogenolysis, but this is irrelevant to its emergency use. It targets airway obstruction, not metabolic states, making this a misaligned choice for its therapeutic intent.

A. Release the client’s restraints every 4 hr. B. Check the client’s status every hour. C. Obtain written consent by the client for the placement of the restraints. D. Document the client’s behavior leading to the initiation of the restraints.

Correct Answer is D

Explanation

Choice A reason: Releasing restraints every 4 hours lacks context; policy requires 2-hour checks with release if safe. Scientifically, this risks neglect, as frequent assessment ensures circulation and safety, making it less precise than behavior documentation.

Choice B reason: Hourly checks are good but not the action specified; 15-minute intervals are standard for restraints. Scientifically, this underestimates risk monitoring needs, as behavior justification is a legal and clinical priority over timing alone.

Choice C reason: Client consent isn’t required for restraints in emergencies; provider orders suffice. Scientifically, imminent harm overrides autonomy, and consent isn’t feasible mid-crisis, making this impractical and misaligned with restraint protocols.

Choice D reason: Documenting behavior justifies restraints, ensuring legal and ethical use for safety. Scientifically, this aligns with standards, as specific actions (e.g., aggression) validate intervention, providing a clinical basis critical for care continuity and review.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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