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A nurse is reviewing assessment data collected from a post-operative patient. What assessment findings would serve as cues that the client may be experiencing hypoactive delirium? Select all that apply.

Slowed psychomotor activity

Impaired attention and concentration

Hallucinations and delusions

Decreased alertness or responsiveness

Agitation and restlessness

Answer and Explanation

Correct Answer : A,B,D

Choice A Reason:

Slowed psychomotor activity.

Slowed psychomotor activity is a hallmark of hypoactive delirium. Patients with this type of delirium often exhibit reduced physical movement and slower reaction times. This symptom can make hypoactive delirium more challenging to recognize compared to the more obvious agitation seen in hyperactive delirium.

Choice B Reason:

Impaired attention and concentration.

Impaired attention and concentration are common in all forms of delirium, including hypoactive delirium. Patients may have difficulty focusing, sustaining, or shifting attention, which can significantly impact their ability to engage in daily activities or follow conversations.

Choice C Reason:

Hallucinations and delusions.

While hallucinations and delusions can occur in delirium, they are more commonly associated with hyperactive delirium. Hypoactive delirium is characterized more by withdrawal and decreased responsiveness rather than the presence of hallucinations or delusions.

Choice D Reason:

Decreased alertness or responsiveness.

Decreased alertness or responsiveness is a key feature of hypoactive delirium. Patients may appear drowsy, lethargic, or less responsive to their environment. This can sometimes be mistaken for depression or fatigue, making it crucial to differentiate hypoactive delirium from other conditions.

Choice E Reason:

Agitation and restlessness.

Agitation and restlessness are characteristic of hyperactive delirium, not hypoactive delirium5. In hypoactive delirium, patients are more likely to be withdrawn and less responsive rather than agitated or restless.

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Correct Answer is A

Explanation

Choice A Reason:

The statement “Autonomy” is correct. Autonomy is the ethical principle that respects an individual’s right to make their own decisions and act on their own values. By allowing clients to choose whether or not to attend group therapy, the unit manager is preserving the clients’ autonomy. This approach acknowledges the clients’ ability to make informed decisions about their own treatment and respects their personal preferences and values1. Autonomy is a fundamental principle in healthcare, emphasizing the importance of respecting patients’ rights to self-determination.

Choice B Reason:

The statement “Justice” is incorrect. Justice refers to the ethical principle of treating individuals fairly and equitably. While justice is an important consideration in healthcare, the policy of allowing clients to choose whether or not to attend group therapy is more directly related to respecting their autonomy rather than ensuring equitable treatment. Justice would be more relevant in ensuring that all clients have equal access to group therapy sessions and resources.

Choice C Reason:

The statement “Beneficence” is incorrect. Beneficence is the ethical principle that involves acting in the best interest of the client and promoting their well-being. While encouraging group therapy can be seen as an act of beneficence, the specific policy of allowing clients to choose whether or not to attend is more aligned with respecting their autonomy. Beneficence focuses on doing good for the client, whereas autonomy emphasizes the client’s right to make their own choices.

Choice D Reason:

The statement “Veracity” is incorrect. Veracity refers to the ethical principle of truthfulness and honesty in interactions with clients. While veracity is crucial in maintaining trust and transparency in the therapeutic relationship, the policy of allowing clients to choose whether or not to attend group therapy is primarily about respecting their autonomy. Veracity would be more relevant in ensuring that clients are fully informed about the benefits and potential risks of group therapy.

A. Hypertension B. Tinnitus C. Metallic taste D. Dizziness

Correct Answer is D

Explanation

Choice A Reason:

Hypertension.

Hypertension, or high blood pressure, is not a common side effect of lorazepam. Lorazepam is a benzodiazepine, which typically causes sedation and relaxation of muscles, leading to a decrease in blood pressure rather than an increase. Therefore, hypertension is not an expected side effect of this medication.

Choice B Reason:

Tinnitus.

Tinnitus, or ringing in the ears, is also not commonly associated with lorazepam use. While tinnitus can be a side effect of various medications, it is not typically linked to benzodiazepines like lorazepam. Therefore, it is not an expected side effect for clients taking this medication.

Choice C Reason:

Metallic taste.

A metallic taste is not a common side effect of lorazepam. This side effect is more often associated with other medications, such as certain antibiotics or chemotherapy drugs. Lorazepam’s side effects are more related to its sedative properties.

Choice D Reason:

Dizziness.

Dizziness is a common side effect of lorazepam. As a central nervous system depressant, lorazepam can cause drowsiness, dizziness, and lightheadedness. Clients should be advised to avoid activities that require alertness, such as driving, until they know how the medication affects them.

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A nurse is reviewing assessment data collected from a post-operative patient. What assessment findings would serve as cues that the client may be experiencing hypoactive delirium? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager’s policy preserve?

Correct Answer is A

Explanation

The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?

Correct Answer is D

Explanation

An inpatient on the psychiatric unit is having a panic attack. An appropriate nursing intervention at this time would be to:

A client diagnosed with an Anxiety Disorder tells a nurse that being in crowds creates thoughts of losing control and the need to suddenly leave. What should the nurse recommend as an effective, non-pharmacological therapy for managing the client’s symptoms of anxiety?

A nurse is caring for a client who is diagnosed with Functional Neurologic Symptom Disorder (conversion disorder). What action should the nurse include in the plan of care?

A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

The nurse is attempting to de-escalate a client who is becoming increasingly agitated on the unit. Which of the following interventions would be appropriate for this type of client? (SELECT ALL THAT APPLY)

A client diagnosed with schizophrenia is prescribed clozapine. The nurse teaches the client and family to call the physician immediately if:

A client diagnosed with Illness Anxiety Disorder is prescribed clonazepam for underlying anxiety. Of the following, which is of utmost importance when caring for this client?