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.

Answer and Explanation

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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Correct Answer is B

Explanation

A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.

B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.

C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.

D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.

A. Allow him to continue the conversation at his own pace. B. Redirect the conversation to assist him in focusing on the topic. C. Stop him and tell him how his conversation sounds to others. D. Use the communication technique of reflecting.

Correct Answer is B

Explanation

A) Incorrect. Allowing the client to continue at his own pace may not effectively address the issue of circumstantiality and could lead to prolonged, tangential conversations.

B) Correct. Redirecting the conversation can help the client refocus and stay on topic, which can be particularly helpful for someone experiencing circumstantiality.

C) Incorrect. Stopping the client and telling him how his conversation sounds to others may be perceived as confrontational and could potentially be distressing for the client.

D) Incorrect. Reflecting is a useful communication technique, but it may not be the most effective intervention for addressing circumstantiality in this scenario.

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A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?

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Naxlex Comprehensive Predictor Exams

An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?

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Explanation

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Correct Answer is B

Explanation

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