Which of the following is an appropriate outcome for a client experiencing an acute episode of delirium?

Client will remain free from self-directed violence as evidenced by agreement to a no-suicide contract.

Client will have intact tactile senses as evidenced by ability to recognize familiar objects when placed in his or her hand.

Client will have decreased confusion as evidenced by orientation to person, place, and time.

Client will verbalize increased feelings of self-esteem as evidenced by statements acknowledging ability to perform certain tasks independently.

Answer and Explanation

The Correct Answer is C

A. Client will remain free from self-directed violence as evidenced by agreement to a no-suicide contract is more appropriate for a patient who is at risk for suicide or self-harm, but it doesn't specifically address delirium, which involves acute confusion and altered consciousness. A no-suicide contract does not directly address the underlying cognitive issues in delirium.
B. Client will have intact tactile senses as evidenced by ability to recognize familiar objects when placed in his or her hand focuses on sensory perception, which may not be the most relevant outcome for a patient experiencing delirium. Delirium primarily affects cognitive functions such as attention, memory, and orientation, rather than tactile sensations.
C. Client will have decreased confusion as evidenced by orientation to person, place, and time is the most appropriate and specific outcome for delirium. Delirium is characterized by acute confusion and disorientation to time, place, and person, and improving orientation is a key goal in managing delirium.
D. Client will verbalize increased feelings of self-esteem as evidenced by statements acknowledging ability to perform certain tasks independently is more relevant for mental health disorders such as depression or anxiety, where self-esteem and independence are key focuses. While important, it is not a priority outcome for delirium, where the main concern is restoring cognitive function.

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Correct Answer is D

Explanation

A. Multiple sclerosis is a chronic neurological condition that affects the central nervous system, but it is not the most common cause of dementia. While some people with multiple sclerosis may develop cognitive changes, it is not a primary cause of dementia.
B. Brain injury can result in cognitive impairments and changes in memory, but it is not the most common cause of dementia. Traumatic brain injury may lead to a type of dementia known as post-traumatic dementia, but it is relatively rare compared to Alzheimer's disease.
C. Huntington chorea (also called Huntington's disease) is a genetic disorder that leads to progressive movement, cognitive, and psychiatric problems. It can cause dementia, but it is a much less common cause compared to Alzheimer's disease.
D. Alzheimer's disease is the most common cause of dementia, accounting for the majority of cases. Alzheimer's is a progressive neurodegenerative disease that primarily affects memory, thinking, and behavior, ultimately impairing a person’s ability to perform daily activities.

A. Childbirth classes to prepare for the birth B. Risks of pregnancy complications caused by abuse C. Instructions on the use of resources available to her D. Available resources on domestic violence

Correct Answer is D

Explanation

A. Childbirth classes to prepare for the birth may be relevant, but they are not the priority in this situation. The immediate concern is the safety and well-being of the pregnant woman and her ability to address the abuse.
B. Risks of pregnancy complications caused by abuse are important to discuss, but the priority at this moment should be ensuring the woman knows where to get help and support regarding the domestic violence she is experiencing.
C. Instructions on the use of resources available to her may be important, but the most immediate concern is ensuring she is aware of domestic violence resources that can help her escape further harm.
D. Available resources on domestic violence should be the priority. The nurse needs to ensure that the woman knows how to access safe spaces and support systems to escape from the abusive relationship. Domestic violence poses immediate risk to both the woman and her pregnancy, and addressing it must be the first step in the care plan.

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Which of the following is an appropriate outcome for a client experiencing an acute episode of delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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