The nurse is caring for a patient diagnosed with delirium. The nurse would note these symptoms as consistent with delirium: Select all that apply.

A: These symptoms are typical of opioid withdrawal. Pain, muscle spasms, diaphoresis (sweating), nausea, and vomiting are common as the body reacts to the absence of the drug.

B: Slurred speech, sedation, hyporeflexia (reduced reflexes), and disorientation are more indicative of opioid intoxication rather than withdrawal.

C: Hypertension and tachycardia can occur during withdrawal, but mental alertness and euphoria are not typical. Euphoria is associated with opioid use, not withdrawal.

D: Paranoid delusions and synesthesia are not typical of opioid withdrawal. Rhinorrhea (runny nose) and lacrimation (tearing) are common, but the other symptoms listed do not align with opioid withdrawal.

A: The patient who is superficial in group therapy may not be engaging deeply with the therapeutic process, which can hinder their progress. However, this behavior does not pose an immediate threat to the safety of others or the therapeutic environment. It is important for the nurse to address this issue to encourage more meaningful participation, but it is not the most urgent concern.

B: The patient who threatens other patients presents an immediate risk to the safety and well-being of others in the unit. Threatening behavior can escalate to physical violence, causing harm to patients and staff. Addressing this behavior first is crucial to maintaining a safe and therapeutic environment. The nurse must intervene promptly to de-escalate the situation, ensure the safety of all individuals, and implement appropriate measures to prevent further threats.

C: The patient who is lying to others in the group can disrupt the trust and cohesion within the therapeutic setting. While honesty is important for effective therapy, this behavior does not pose an immediate danger. The nurse should address this issue to maintain the integrity of the group therapy process, but it is not as urgent as addressing threats of violence.

D: The patient who makes sexual jokes may be engaging in inappropriate behavior that can make others uncomfortable and disrupt the therapeutic environment. While this behavior needs to be addressed to maintain a respectful and professional atmosphere, it does not pose an immediate threat to safety. The nurse should intervene to correct this behavior, but it is not the highest priority compared to threats of violence.