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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This

intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.

B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.

C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.

D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.

A. Administer thiamine intramuscular (IM) B. Assist the client with personal hygiene needs C. Place the client on continuous observation D. Explain milieu therapy

Correct Answer is B

Explanation

A. Administer thiamine intramuscular (IM) Administering thiamine is important, especially in
clients with alcohol abuse, to prevent or treat potential Wernicke Korsakoff syndrome. However, the primary intervention when admitting a client is addressing immediate physical and psychological needs, such as personal hygiene.

B. Assist the client with personal hygiene needs This is the primary intervention upon admission.
It addresses the client's immediate physical and psychological wellbeing and helps establish a therapeutic rapport.

C. Place the client on continuous observation While observation may be necessary for safety, it is not the primary intervention in this scenario. Addressing personal hygiene needs takes precedence.

D. Explain milieu therapy Milieu therapy is an important aspect of a comprehensive treatment plan, but it is not the primary intervention upon admission. Immediate physical care and safety are the initial priorities.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Correct Answer is A

Explanation

The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

Correct Answer is B

Explanation

During the admission process, an elderly client is asked to present their license for identification purposes. The client gives the admission personnel their glasses. This is an example of which of the following symptoms of dementia?

A client diagnosed with major depressive disorder is considering cognitive behavioral therapy. The client asks the nurse how this therapy would help alleviate depressive thoughts. What is the best response by the nurse?

A client diagnosed with bipolar II disorder has a problem statement of impaired social interactions related to egocentrism. Which short-term correctly written outcome is an appropriate expectation for this client problem?

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. What information should be included in the teaching? (Select all that apply.)

The client is experiencing a manic episode. Which of the following activities will be included in the plan of care?

The nurse is teaching about obstacles to maintaining recovery. Which of the following statements would indicate to the nurse a greater risk for relapse? (Select all that apply.)

The nurse receives report on a male client diagnosed with schizoaffective disorder and is informed that the client's verbal communication includes "circumstantiality." What intervention is most therapeutic when caring for this client?

The nurse states in report that the client is experiencing positive symptoms of schizophrenia. What symptoms would the nurse receiving report expect to observe?