A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?

"This is supposed to happen when you get old, right?”

"Since his mother died, he has not been feeling well.”

"My husband just didn't seem to know what he was doing. He has been forgetful for years.”

"The changes in his behavior came on so quickly! I wasn't sure what was happening.”

Answer and Explanation

The Correct Answer is D

Choice A rationale:

"This is supposed to happen when you get old, right?" is a common misconception but doesn't necessarily support the diagnosis of delirium. It could be attributed to normal aging changes.

Choice B rationale:

"Since his mother died, he has not been feeling well." indicates a potential stressor but doesn't directly address the rapid onset of behavioral changes, which is a hallmark of delirium.

Choice C rationale:

"My husband just didn't seem to know what he was doing. He has been forgetful for years." suggests a history of forgetfulness rather than an acute change in behavior, which is more indicative of chronic cognitive issues like dementia.

Choice D rationale:

(Correct) "The changes in his behavior came on so quickly! I wasn't sure what was happening." This statement supports the diagnosis of delirium, which is characterized by a sudden onset of confusion and changes in cognitive function. Delirium often develops rapidly, and the client's wife's observation aligns with this diagnostic criterion.

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Correct Answer is A

Explanation

Choice A rationale:

Twisting tongue movements are characteristic manifestations of tardive dyskinesia (TD). TD is a movement disorder associated with long-term use of antipsychotic medications like fluphenazine (Prolixin). These involuntary movements often involve the face and tongue and can be irreversible if not addressed promptly.

Choice B rationale:

Constant tapping of feet when sitting is not a typical manifestation of tardive dyskinesia. This type of movement might be related to restlessness or anxiety, but it is not specifically associated with the movement disorder caused by prolonged antipsychotic use.

Choice C rationale:

Shuffling gait can be associated with parkinsonism, which is another potential adverse effect of antipsychotic medications, including fluphenazine. However, for tardive dyskinesia, the characteristic movements are more often related to the face and mouth rather than the legs and gait.

Choice D rationale:

Sudden onset of high fever is not a manifestation of tardive dyskinesia. It could potentially be a sign of a different medical issue, such as an infection. However, it is not directly related to the movement disorder caused by long-term antipsychotic use.

A. "You need to tell the voices to leave you alone.” B. "You need to understand that there are no voices.” C. "What are the voices telling you to do?” D. "Why do you think you are hearing the voices?”

Correct Answer is C

Explanation

Choice A rationale:

Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.

Choice B rationale:

Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.

Choice C rationale:

This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.

Choice D rationale:

Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.

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A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client diagnosed with schizophrenia, which has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?

Correct Answer is A

Explanation

A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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