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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Demonstrating genuineness involves being authentic, sincere, and transparent in interactions with clients. This helps build trust by showing that the nurse's intentions and emotions align with their words. Genuineness fosters a sense of safety and openness in the therapeutic relationship.
Choice B rationale:
While focusing on the words of the clients is important, it's not the only factor. Nonverbal cues, emotions, and context also play significant roles in effective communication. Only focusing on words could result in missing important nuances and emotions.
Choice C rationale:
Controlling the pace of the nurse-client relationship contradicts the principle of client-centered care, where the client's readiness and comfort should guide the pace. Pushing the pace might lead to resistance or discomfort, hindering the development of trust.
Choice D rationale:
Providing sympathy involves expressing pity or sorrow for the client's situation. However, empathy, which involves understanding and sharing the client's feelings, is more appropriate. Sympathy might create a sense of pity, while empathy establishes a deeper connection and understanding.
Correct Answer is D
Explanation
Choice A rationale:
Existing conditions can indeed be a predisposing factor for stress. Chronic medical conditions, financial difficulties, or interpersonal conflicts can contribute to increased stress levels. These existing conditions create a foundation for stress to manifest.
Choice B rationale:
Heredity can also play a role in predisposing individuals to stress. Genetic factors can influence how a person responds to stressors and copes with challenging situations. A family history of anxiety disorders, for example, might increase an individual's susceptibility to stress.
Choice C rationale:
Learned responses are another predisposing factor for stress. If an individual has experienced traumatic events or has learned maladaptive coping mechanisms in response to stressors, they may be more prone to feeling stressed when faced with similar situations in the future.
Choice D rationale:
History of hypotension is the correct answer. Hypotension refers to abnormally low blood pressure. While it can have its own effects on the body, it is not typically considered a predisposing factor for stress. Stress is more closely associated with psychological and environmental factors rather than a person's blood pressure history.
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