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.

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Correct Answer is B

Explanation

Choice A reason: Diarrhea and weight gain are less common with SSRIs. While some SSRIs may cause gastrointestinal upset via serotonin receptor stimulation in the gut, weight gain is more associated with atypical antipsychotics. SSRIs primarily affect serotonin reuptake, leading to central and anticholinergic-like effects, not these symptoms predominantly.

Choice B reason: SSRIs, by inhibiting serotonin reuptake, cause dizziness, drowsiness, and dry mouth due to central nervous system effects and mild anticholinergic activity. Dizziness and drowsiness result from serotonin modulation in the brainstem, while dry mouth reflects peripheral serotonin effects on salivary glands, making these the most common side effects.

Choice C reason: Convulsions and respiratory difficulties are rare with SSRIs. Seizures may occur in overdose due to excessive serotonin, but not typically at therapeutic doses. Respiratory issues are not associated, as SSRIs primarily affect serotonin pathways, not respiratory centers, making this choice inaccurate for common side effects.

Choice D reason: Jaundice and agranulocytosis are not common SSRI side effects. These are associated with drugs like chlorpromazine, affecting liver or bone marrow. SSRIs primarily cause serotonin-related central and peripheral effects, not hepatotoxicity or bone marrow suppression, making this choice irrelevant to their pharmacological profile.

A. 2 tsp B. 3 tsp C. 1 tsp D. 4 tsp

Correct Answer is C

Explanation

Choice A reason: Administering 2 teaspoons (10 mL) would deliver 500 mg of Amoxicillin, as the concentration is 250 mg/5 mL, and 1 teaspoon equals 5 mL. This dose is double the prescribed 250 mg, risking overdose. Amoxicillin overdose can cause gastrointestinal distress or, in rare cases, renal toxicity, making this choice scientifically inappropriate for the prescribed dose.

Choice B reason: Giving 3 teaspoons (15 mL) would deliver 750 mg of Amoxicillin, far exceeding the prescribed 250 mg dose. The concentration is 250 mg/5 mL, so 15 mL contains three times the required amount. This could lead to adverse effects like diarrhea or allergic reactions, as excessive antibiotic levels disrupt gut flora and increase toxicity risks.

Choice C reason: One teaspoon (5 mL) delivers exactly 250 mg of Amoxicillin, matching the prescribed dose, as the concentration is 250 mg/5 mL. This ensures therapeutic efficacy for treating infections like otitis media in children, maintaining serum levels within the therapeutic range (MIC for common pathogens like Streptococcus pneumoniae), minimizing side effects, and adhering to pediatric dosing guidelines.

Choice D reason: Four teaspoons (20 mL) would deliver 1000 mg of Amoxicillin, four times the prescribed dose. At 250 mg/5 mL, this excessive dose risks severe side effects, including nephrotoxicity or hepatotoxicity, and disrupts microbial balance, potentially causing antibiotic resistance. This is scientifically inappropriate, as it deviates significantly from the therapeutic dose for an 8-year-old.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What are the most common types of side effects from SSRIs?

Correct Answer is B

Explanation

Bobby is an 8-year-old patient who is to receive Amoxicillin 250 mg every 8 hours. You have 250 mg/5 mL. How many teaspoons will you tell his mother to administer every 8 hours?

Correct Answer is C

Explanation

The nurse is caring for a client admitted with severe exacerbation of posttraumatic stress disorder that is experiencing flashbacks and hypervigilance. Which is the priority for the nurse to address when caring for this client?

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

Which of the following statements by the caregiver of a client newly diagnosed with dementia requires further intervention by the nurse?

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Identify the serum lithium level for maintenance and safety.

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