An 80 year-old client, together with his daughter, arrived at the medical surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?

"Maybe it's just caused by aging. This usually happens at his age."

"The changes in his behavior came on so quickly! I wasn't sure what was happening."

"Dad just didn't seem to know what he was doing. He has been forgetful for years."

"Dad has always been so independent. He's lived alone for years since Mom died."

Answer and Explanation

The Correct Answer is B

A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.

B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.

C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.

D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.

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Correct Answer is C

Explanation

A. Encouraging descriptions of perceived failures may further exacerbate the client's poor self- esteem and is not a therapeutic intervention.
B. While setting limits is important in managing behavior, it may not directly address the underlying issue of poor self-esteem.
C. Providing activities that can be accomplished can help boost the client's confidence and self- esteem.
D. Teaching aggressive communication skills is not appropriate and may contribute to further negative self-perception.

A. Administer diazepam B. Raise the side rails of the bed C. Obtain a medical history D. Start intravenous fluids

Correct Answer is D

Explanation

A. Administering diazepam may be part of the treatment plan for delirium tremens, but ensuring adequate hydration and addressing potential electrolyte imbalances is the first priority.
B. Raising the side rails is important for safety, but it is not the highest priority action at this time.
C. Obtaining a medical history is important for comprehensive care, but in this urgent situation, addressing fluid and electrolyte balance is the first priority.
D. Starting intravenous fluids is crucial for rehydration and addressing potential electrolyte imbalances, which is the priority in this emergency situation.

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An 80 year-old client, together with his daughter, arrived at the medical surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with poor self-esteem. What intervention would be important for the nurse to include in the plan of care?

Correct Answer is C

Explanation

A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

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