A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?
A decreased level of consciousness with intermittent periods of hypervigilance.
A slow onset of confusion and agitation.
A decrease in the client's output and vital signs.
The symptoms have lasted longer than a month.
The Correct Answer is A
A. Delirium is characterized by a fluctuating level of consciousness, which can include periods of hypervigilance.
B. A slow onset of confusion and agitation is more characteristic of dementia rather than delirium.
C. A decrease in output and vital signs may indicate a different condition, but it is not specific to delirium.
D. Delirium is characterized by an acute onset and is typically short-lived, usually lasting days to weeks. Symptoms lasting longer than a month would suggest a different diagnosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This option describes a feeling of burden, but it doesn't specifically address persecution.
B. This option describes a delusion involving a familial relationship with a public figure, but it doesn't specifically address persecution.
C. This option describes a command hallucination, which can be related to violence, but it doesn't directly address feeling persecuted.
D. This option directly addresses the feeling of persecution by believing a powerful agency is actively seeking to harm the client.
Correct Answer is ["B","C","D"]
Explanation
A) Incorrect. While it's important to avoid dehydration, this option is not specific to lithium use.
B) Correct. Lithium can cause dehydration, so it's crucial for the client to drink adequate fluids daily.
C) Correct. A low sodium diet is important while taking lithium, as high sodium levels can affect lithium absorption and potentially lead to toxicity.
D) Correct. Routine blood work is necessary to monitor lithium levels and ensure the client's levels remain within the therapeutic range.
E) Incorrect. Dependency is not a common concern with lithium.
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