A patient admitted to the medical-surgical unit was recently weaned from a mechanical ventilator and an IV infusion of lorazepam.
The patient has been alert and oriented for 24 hours but is now experiencing confusion.
The practical nurse assists the registered nurse with the evaluation of new-onset confusion by assessing the patient’s sense of place and time, difficulty focusing, short-term memory loss, and increased lethargy.
What condition does the practical nurse suspect in this patient?
Psychosis.
Dementia.
Amnesia.
Delirium.
The Correct Answer is D
Choice D rationale
Delirium is a sudden onset of confusion that can be caused by a variety of factors, including withdrawal from certain medications like lorazepam. Symptoms can include disorientation, difficulty focusing, short-term memory loss, and increased lethargy.
Choice A rationale
Psychosis is a severe mental disorder characterized by a disconnection from reality. It often involves hallucinations or delusions, which are not mentioned in the scenario.
Choice B rationale
Dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury. It is marked by memory disorders, personality changes, and impaired reasoning. It typically does not have a sudden onset.
Choice C rationale
Amnesia is a condition in which one’s memory is lost or disturbed. It can be caused by brain injury or severe emotional trauma. The scenario does not provide information suggesting the patient has experienced a loss of memory.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While making a verbal contract not to harm oneself can be a part of suicide prevention strategies, it is not the immediate responsibility in this scenario. The client’s erratic behavior and expressions of despair indicate a high level of distress and potential risk for self-harm.
Choice B rationale
Returning the client to the waiting room with the spouse does not ensure the client’s safety. The spouse may not be equipped to manage the client’s current emotional state, and the busy environment of the waiting room may exacerbate the client’s distress.
Choice C rationale
Documenting that the client is not currently suicidal is not appropriate in this situation. The client’s non-verbal cues (shrugging their shoulders when asked about suicidal thoughts) may indicate ambivalence or uncertainty about their intent to harm themselves.
Choice D rationale
Placing the client in an inside hallway with one-on-one observation is the most appropriate action. This ensures the client’s safety, allows for continuous monitoring of the client’s condition, and provides an opportunity for further assessment and intervention.
Correct Answer is D
Explanation
Choice D rationale
Delirium is a sudden onset of confusion that can be caused by a variety of factors, including withdrawal from certain medications like lorazepam. Symptoms can include disorientation, difficulty focusing, short-term memory loss, and increased lethargy.
Choice A rationale
Psychosis is a severe mental disorder characterized by a disconnection from reality. It often involves hallucinations or delusions, which are not mentioned in the scenario.
Choice B rationale
Dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury. It is marked by memory disorders, personality changes, and impaired reasoning. It typically does not have a sudden onset.
Choice C rationale
Amnesia is a condition in which one’s memory is lost or disturbed. It can be caused by brain injury or severe emotional trauma. The scenario does not provide information suggesting the patient has experienced a loss of memory.
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