A nurse is collecting data from an older adult client who was admitted with heart failure.
The nurse should report which of the following findings to the provider as an indication of delirium? .
Consistent state of depression
Fluctuating level of orientation.
Demonstrates obsessive behaviors.
Family report of gradual memory loss.
The Correct Answer is B
Choice A rationale:
A consistent state of depression is not indicative of delirium, but rather a mood disorder.
Choice B rationale:
Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
Choice C rationale:
Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
Choice D rationale:
Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Ringing in the ears is not a common side effect of haloperidol.
Choice B rationale:
A metallic taste is not typically associated with haloperidol use.
Choice C rationale:
Urinary incontinence is not a known side effect of haloperidol.
Choice D rationale:
Haloperidol can cause photosensitivity, making the skin more sensitive to the sun.
Correct Answer is B
Explanation
Choice A rationale:
This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.
Choice B rationale:
This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.
Choice C rationale:
This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.
Choice D rationale:
This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.
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