A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?

"Delirium has an abrupt onset."

"Delirium does not affect a client's sleep cycle."

"Delirium has a slow progression."

"Delirium does not affect a client's perception of her environment."

Answer and Explanation

The Correct Answer is A

Choice A reason:
Delirium is a sudden and acute change in mental status characterized by confusion, disorientation, altered consciousness, and other cognitive disturbances. It has an abrupt onset and is often related to an underlying medical condition, medication, or other factors such as infections or metabolic imbalances.
Choice B reason:
Delirium can indeed affect a client's sleep cycle. It often disrupts sleep patterns and can lead to sleep disturbances
Choice C reason:
Delirium does not have a slow progression. It is typically characterized by a rapid and fluctuating course, and it can develop over hours to days.
Choice D reason:
Delirium does affect a client's perception of their environment. Clients with delirium may experience hallucinations, paranoia, and other alterations in perception. They may be unable to accurately interpret or interact with their surroundings.

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Correct Answer is C

Explanation

Choice A reason:
ALT is not primarily used to check kidney function. Kidney function is typically assessed through other tests, such as blood urea nitrogen (BUN) and creatinine levels.
Choice B reason:
ALT is not used to assess the risk of blood clots. It is specifically related to liver function.
Choice C reason:
Alanine aminotransferase (ALT) is an enzyme found primarily in the liver. An elevated ALT level in the blood can indicate potential liver damage or disease, so the ALT test is used to assess the function of the liver.
Choice D reason:
ALT is not a test to determine heart performance. Heart function is evaluated using tests such as electrocardiograms (ECGs) or cardiac enzymes.

A. Shakiness B. Cool skin C. Thirst D. Confusion

Correct Answer is C

Explanation

A. Shakiness (tremors) is more commonly associated with hypoglycemia, where blood glucose levels drop too low. It is not typically a symptom of hyperglycemia. B. Cool skin is not a typical symptom of hyperglycemia. It is more commonly associated with poor peripheral circulation, which can occur in diabetes but is not specific to hyperglycemia itself. C. Thirst (polydipsia) is a common symptom of hyperglycemia in clients with diabetes mellitus. When blood glucose levels are elevated, the kidneys work to eliminate the excess glucose through urine, leading to increased urine production (polyuria). This increased urine production can result in dehydration, triggering the sensation of thirst as the body tries to maintain fluid balance. Thirst is a more common early indicator. D. Confusion can occur in severe cases of both hyperglycemia (diabetic ketoacidosis) and hypoglycemia. However, it is not specific enough on its own to indicate hyperglycemia without other symptoms like thirst and polyuria.

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A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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