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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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Using restraints can lead to injury and is generally a last resort.

Choice B rationale:

Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.

Choice C rationale:

Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.

Choice D rationale:

While medication can be helpful, non-pharmacological interventions should be tried first.

A. Administer an antianxiety medication B. Calculate the client's score on the Hamilton Rating Scale for Anxiety. C. Explain the use of response prevention to the client. D. Discuss the benefits of relaxation exercises with the client.

Correct Answer is B

Explanation

Choice A rationale:

Administering an antianxiety medication can help manage symptoms, but it’s not the first action a nurse should take.

Choice B rationale:

Calculating the client’s score on the Hamilton Rating Scale for Anxiety is the first step in assessing the severity of the client’s anxiety.

Choice C rationale:

Explaining the use of response prevention can be beneficial, but it’s not the first action the nurse should take.

Choice D rationale:

Discussing the benefits of relaxation exercises can help manage anxiety, but it’s not the first action the nurse should take.

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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? .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?.

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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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? .