A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?
Demonstrates obsessive behaviors
Fluctuating level of orientation
Family report of gradual memory loss
Consistent state of depression
The Correct Answer is B
A. Obsessive behaviors, such as repetitive actions or fixations on specific thoughts or tasks, can be indicative of delirium. Delirium often manifests with altered behavior patterns that are unusual for the individual, including obsessive or compulsive-like behaviors that are not typical of their baseline mental status. However, this is not specific to delirium.
B. Fluctuating orientation, where the client is sometimes alert and oriented and at other times confused or disoriented, is a hallmark of delirium. Unlike dementia, which typically presents with a more steady decline in cognitive function, delirium is characterized by rapid changes in mental status over hours to days. This fluctuation is important to note as it strongly suggests delirium rather than other chronic cognitive impairments.
C. Gradual memory loss reported by family members is more suggestive of chronic conditions such as dementia rather than delirium. Delirium, in contrast, is characterized by acute onset and fluctuating course rather than a gradual decline in cognitive abilities over time.
D. Depression can coexist with delirium, but a consistent state of depression without acute changes in mental status is less indicative of delirium. Delirium is characterized by rapid changes in cognition and behavior rather than a persistent mood disorder. Therefore, while depression should be assessed and managed appropriately, it is not typically a sign of delirium unless there are acute changes in mental status accompanying it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Unlike anorexia nervosa, where individuals typically appear underweight, people with bulimia nervosa often maintain a body weight within the normal or even overweight range. This can make it challenging to identify based on physical appearance alone, as individuals may hide their binge-eating and purging behaviors.
B. Individuals with bulimia nervosa often engage in episodes of binge-eating, during which they consume large amounts of food in a short period and feel a loss of control over their eating. This is followed by compensatory behaviors such as self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise to prevent weight gain.
C. Bulimia nervosa does not directly increase the risk of developing diabetes mellitus. However, the binge-eating episodes characteristic of bulimia can lead to metabolic disturbances and insulin resistance over time. This can potentially increase the risk of developing type 2 diabetes in individuals who are predisposed or have other risk factors.
D. While self-induced vomiting is a common purging method in bulimia nervosa, there are other ways individuals may attempt to compensate for binge-eating episodes, such as excessive exercise, fasting, or misuse of laxatives or diuretics. The key diagnostic criteria for bulimia nervosa include recurrent episodes of binge-eating and inappropriate compensatory behaviors to prevent weight gain.
Correct Answer is A
Explanation
A. Dual diagnosis treatment programs are specifically designed for individuals who have both a mental health disorder (such as ASPD) and a substance use disorder (alcohol dependency in this case). These programs integrate treatment approaches that address both conditions concurrently. They typically involve a combination of medication management, psychotherapy, and support groups tailored to dual diagnosis clients. Encouraging the client to participate in a dual diagnosis treatment group can help address the complex interplay between ASPD and alcohol dependency.
B. Codependency support groups focus on relationships where one person may enable or support dysfunctional behavior in another person. While relevant in certain contexts, codependency support groups may not directly address the primary issues of ASPD and alcohol dependency. Therefore, this option is less appropriate compared to dual diagnosis treatment for this client.
C. Psychodrama is a form of therapy where clients act out real-life situations to explore and gain insights into their feelings, behaviors, and relationships. While psychodrama can be beneficial for emotional expression and role-playing, it may not directly target the core symptoms and challenges of ASPD and alcohol dependency. Therefore, it may not be the most effective intervention for this client compared to dual diagnosis treatment.
D. Crisis intervention focuses on immediate stabilization and support during a mental health crisis or acute episode. While crisis intervention may be necessary at times, it is not a comprehensive treatment approach for ASPD and alcohol dependency. Long-term management and therapeutic interventions, such as dual diagnosis treatment, are typically needed to address these chronic conditions effectively.
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