When assessing a client with delirium, the nurse will expect to see (Select all that apply)

Aphasia

Confusion

Impaired level of consciousness

Long-term memory impairment

Mood fluctuations

Rapid onset of symptoms

Answer and Explanation

Correct Answer : B,C,F

Choice A reason: Aphasia, a language impairment, is not a hallmark of delirium but is associated with neurological conditions like stroke affecting Broca’s or Wernicke’s areas. Delirium involves acute cognitive dysfunction due to underlying causes like infection or hypoxia, primarily affecting attention and awareness, not specific language processing, making this choice scientifically inaccurate for delirium.

Choice B reason: Confusion is a core feature of delirium, characterized by disorientation and impaired attention due to acute brain dysfunction. It results from disruptions in cerebral metabolism, often triggered by systemic issues like electrolyte imbalances or sepsis. This symptom distinguishes delirium from dementia, as it reflects rapid, reversible cognitive changes, requiring immediate assessment.

Choice C reason: Impaired level of consciousness, such as fluctuating alertness or stupor, is a defining feature of delirium. It stems from diffuse brain dysfunction, often due to toxic, metabolic, or infectious causes affecting neurotransmitter balance or cerebral perfusion. This distinguishes delirium from dementia, which typically preserves consciousness, making this a critical diagnostic criterion.

Choice D reason: Long-term memory impairment is characteristic of dementia, not delirium. Delirium involves acute, reversible cognitive deficits, primarily affecting attention and short-term memory due to transient brain dysfunction. Long-term memory remains relatively intact in delirium, as the underlying pathology does not typically involve chronic neuronal loss, unlike Alzheimer’s or other dementias.

Choice E reason: Mood fluctuations occur in delirium due to acute brain dysfunction affecting emotional regulation, often linked to neurotransmitter imbalances or systemic stressors like infection. However, they are not a primary diagnostic criterion compared to confusion, impaired consciousness, and rapid onset, as they may also occur in other psychiatric conditions, reducing specificity.

Choice F reason: Rapid onset of symptoms is a hallmark of delirium, distinguishing it from dementia’s gradual progression. Symptoms develop over hours to days due to acute insults like hypoxia, infection, or medication toxicity, disrupting cerebral function. This rapid timeline is critical for diagnosis, as it indicates a reversible condition requiring urgent intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Depression involves slowed cognitive processing due to serotonin and prefrontal cortex dysfunction, causing delayed responses. Allowing time respects this neurobiological delay, reducing pressure and potential withdrawal. This supports engagement, as the client may formulate a goal with patience, aligning with therapeutic strategies for depressive cognitive deficits.

Choice B reason: Prompting for a response may increase anxiety in depression, where serotonin dysregulation impairs cognitive fluency. Immediate pressure risks disengagement, as the client’s slowed prefrontal processing struggles to respond quickly. Allowing time is more effective, as it accommodates the neurobiological delays characteristic of depressive cognitive function.

Choice C reason: Moving to the next client dismisses the depressed client’s engagement, exacerbating feelings of worthlessness linked to serotonin and dopamine imbalances. This risks reinforcing social withdrawal, a common depressive symptom, as the client’s prefrontal cortex struggles with participation. Allowing time supports inclusion and respects cognitive delays.

Choice D reason: Offering a goal suggestion may reduce autonomy in depression, where prefrontal cortex dysfunction already impairs decision-making. This risks dependency rather than empowering the client, whose serotonin-related cognitive delays require patience to formulate personal goals, making this less effective than allowing time for self-directed thought.

A. Fine motor tremors are an early effect of lithium therapy that usually subsides in a few weeks B. It is nothing to worry about unless it continues for the next month C. You can expect tremors with lithium. You seem very concerned about such a small tremor D. Tremors can be an early sign of toxicity, but we'll keep monitoring your lithium level to make sure you're okay E. The correct answer is: a) Fine motor tremors are an early effect of lithium therapy that usually subsides in a few weeks

Correct Answer is A

Explanation

Choice A reason: Fine motor tremors are a common early side effect of lithium, affecting cerebellar function due to its narrow therapeutic index and sodium channel interactions. These typically subside within weeks as the body adjusts to stable serum levels (0.5–1.2 mEq/L), making this an accurate, reassuring response.

Choice B reason: Dismissing tremors as unimportant unless persistent for a month is incorrect. Lithium tremors, linked to cerebellar effects, often resolve sooner, but persistent tremors may indicate toxicity (levels >1.5 mEq/L), risking neurological damage. This response delays necessary monitoring, ignoring the drug’s neuropharmacological impact.

Choice C reason: Acknowledging tremors but implying the client’s concern is excessive is dismissive. Tremors result from lithium’s cerebellar effects, a legitimate side effect. This response fails to educate about the expected resolution timeline or need for monitoring, risking patient distrust and ignoring the drug’s neurobiological effects.

Choice D reason: Labeling tremors as a potential toxicity sign is misleading, as early fine tremors are typically benign, not indicative of toxicity (>1.5 mEq/L), which involves severe symptoms like confusion. This overstates risk, causing unnecessary alarm, and does not address the common, transient cerebellar effect of lithium.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When assessing a client with delirium, the nurse will expect to see (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client with bipolar disorder begins taking lithium carbonate, 300 mg four times a day. After 3 days of therapy, the client says, "My hands are shaking." The best response by the nurse is which of the following?

Correct Answer is A

Explanation

A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client approaches the nurse and states, "I’m going to take a walk outside. I'll be back in about 10 minutes." Which is the most appropriate nursing action?

Which nursing diagnosis should be most useful for clients with anxiety disorders for whom the following defining characteristics have been identified: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, numbing, and flashbacks?

Tylenol with Codeine 1T is equivalent to how many mL?

Which of the following principles should the nurse apply when planning nursing care for a client who was admitted after a suicide attempt?

Seasonal Affective Disorder is a disturbance of mood and behavior accompanied by at least 5 key features for at least 2 weeks.

Which of the following would indicate an increased suicidal risk? (Select all that apply)

The nurse has been teaching the caregiver about Aricept. The nurse knows teaching has been effective by which of the following statements?