The nurse has reviewed the nurses’ notes, provider’s note, and laboratory results at 0230.
For each client’s finding, specify if the finding is consistent with delirium or Alzheimer’s disease. Each finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row.
Sudden onset of confusion
Hallucinations
Agitation
Current medical diagnosis
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}
a. Sudden onset of confusion
Delirium: Yes. Sudden onset of confusion is a common symptom of delirium, which can develop over hours or days.
Alzheimer’s disease: No. Alzheimer’s disease typically involves a gradual decline in memory, thinking, and reasoning skills.
b. Hallucinations
Delirium: Yes. Hallucinations are a symptom of delirium.
Alzheimer’s disease: Yes. While not as common, hallucinations can occur in later stages of Alzheimer’s disease.
c. Agitation
Delirium: Yes. Agitation is a common symptom of delirium.
Alzheimer’s disease: Yes. Agitation can occur in Alzheimer’s disease, particularly in the middle and later stages.
d. Current medical diagnosis
Delirium: Yes. The client’s current diagnosis is delirium secondary to a urinary tract infection and dehydration.
Alzheimer’s disease: No. The client’s current diagnosis does not indicate Alzheimer’s disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Documenting the client's behavior every 60 minutes is important for monitoring the client's condition and ensuring their safety. However, it is not the most immediate action required following the initiation of seclusion. Continuous documentation helps in assessing the effectiveness of the intervention and making necessary adjustments to the care plan.
Choice B Reason:
Keeping the client in seclusion for no longer than 6 hours is a guideline to prevent prolonged isolation, which can have negative psychological effects. However, this is not the first action the nurse should take. The duration of seclusion should be based on the client's behavior and the clinical judgment of the healthcare team.
Choice C Reason:
Obtaining a prescription for seclusion within 30 minutes is crucial because it ensures that the use of seclusion is medically justified and legally documented. This action aligns with regulatory requirements and best practices in mental health care. It ensures that the intervention is necessary and that the client's rights are protected.
Choice D Reason:
Monitoring the client's vital signs every 4 hours is essential for assessing the client's physical health and detecting any adverse effects of seclusion. However, like documenting behavior, it is not the most immediate action required. Regular monitoring helps in ensuring the client's safety and well-being during the period of seclusion.
Correct Answer is B
Explanation
Choice A reason:
The statement "Identify when the client engages in splitting behaviors" is not appropriate for schizoid personality disorder. Splitting behaviors are more commonly associated with borderline personality disorder, where individuals may view others as all good or all bad. Schizoid personality disorder is characterized by a preference for solitary activities and emotional detachment.
Choice B reason:
The statement "Give the client a choice of solitary activities" is the correct response. Individuals with schizoid personality disorder often prefer solitary activities and may feel more comfortable engaging in them. Providing options for solitary activities respects their preferences and helps them feel more at ease in the care environment.
Choice C reason:
The statement "Assist the client in identifying sources of anger" is not typically relevant for schizoid personality disorder. These individuals often appear emotionally detached and may not express anger or other strong emotions openly. This intervention is more suited for personality disorders where emotional dysregulation is a primary concern.
Choice D reason:
The statement "Set limits on the client's need for constant social contact with others" is not applicable. Clients with schizoid personality disorder usually do not seek constant social contact; instead, they prefer to be alone and avoid social interactions. Setting limits on social contact is unnecessary and does not address their primary needs.
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