The nurse has reviewed the nurses’ notes, provider’s note, and laboratory results at 0230.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason:
Verbalizing an improved mood is a positive outcome, but it is not specific to borderline personality disorder (BPD). Clients with BPD often struggle with interpersonal relationships and emotional regulation. While mood improvement is beneficial, it does not directly address the core issues of BPD, such as difficulty in expressing needs and managing relationships.

Choice B Reason:
Attending to personal hygiene is important for overall health and well-being, but it is not a primary focus in the treatment of BPD. Clients with BPD may have issues with self-care during depressive episodes, but the primary treatment goals usually revolve around emotional regulation, interpersonal effectiveness, and distress tolerance.

Choice C Reason:
Communicating needs is a crucial outcome for clients with BPD. One of the core challenges in BPD is difficulty in expressing emotions and needs effectively, which often leads to interpersonal conflicts and emotional distress. Improving communication skills can help clients build healthier relationships and manage their emotions more effectively. This outcome aligns with therapeutic goals in treatments like Dialectical Behavior Therapy (DBT), which focuses on enhancing interpersonal effectiveness.

Choice D Reason:
Reporting a decrease in hallucinations is not typically associated with BPD. Hallucinations are more commonly linked to psychotic disorders such as schizophrenia. While some clients with BPD may experience transient psychotic symptoms under extreme stress, these are not the primary focus of treatment. The main treatment goals for BPD involve managing emotional dysregulation and improving interpersonal relationships.

A. "Have you noticed that your taste has decreased?" B. "Have you noticed a ringing in your ears?" C. "Have you noticed an increase in thirst?" D. "Have you noticed unintentional weight loss?"

Correct Answer is C

Explanation

Choice A reason:
The statement "Have you noticed that your taste has decreased?" is not a common side effect of olanzapine. Olanzapine is an atypical antipsychotic used to treat schizophrenia and bipolar disorder. Common side effects include weight gain, drowsiness, and increased appetite, but changes in taste are not typically reported.

Choice B reason:
The statement "Have you noticed a ringing in your ears?" is also not a common side effect of olanzapine. Tinnitus (ringing in the ears) is not associated with olanzapine use. More common side effects include dizziness, dry mouth, and constipation.

Choice C reason:
The statement "Have you noticed an increase in thirst?" is the correct response. Olanzapine can cause hyperglycemia (high blood sugar), which can lead to increased thirst and urination. Monitoring for signs of hyperglycemia is important in clients taking olanzapine.

Choice D reason:
The statement "Have you noticed unintentional weight loss?" is not typical for clients taking olanzapine. In fact, weight gain is a more common side effect of olanzapine, along with increased appetite.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?

Correct Answer is C

Explanation

A nurse is obtaining a history from a client who has been taking olanzapine to treat schizophrenia. Which of the following questions should the nurse ask the client?

Correct Answer is C

Explanation

A nurse is teaching the caregiver of a client who has advanced Alzheimer's disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching?

A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?

A nurse is caring for a client who has dementia and is experiencing anticipatory grief. Which of the following actions should the nurse take?

A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is caring for a school-age child who has conduct disorder and is in physical restraints after becoming physically aggressive toward other clients on the unit. Which of the following actions should the nurse take?

A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medications?

A nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take?

A nurse is visiting with the partner of a client who recently died. The partner expresses guilt that they did not do more for their partner. Which of the following responses should the nurse make?