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 ["B","C","D","E"]
Explanation
Choice A rationale:
Misplacing car keys is a common occurrence in many people's lives and is not necessarily indicative of Alzheimer's disease. It can happen to anyone due to various factors like stress or distraction.
Choice B rationale:
Difficulty performing familiar tasks is a potential early warning sign of Alzheimer's disease. This can include tasks that the person previously did with ease, such as cooking or dressing themselves. Alzheimer's disease affects cognitive abilities, including the ability to perform familiar tasks.
Choice C rationale:
Losing sense of time is another potential early warning sign of Alzheimer's disease. People with Alzheimer's may lose track of days or seasons, as the disease impacts their sense of time and memory.
Choice D rationale:
Problems with performing basic calculations can be a sign of cognitive decline, but it is not one of the primary early warning signs of Alzheimer's disease. This choice is less specific to Alzheimer's and could be related to other cognitive disorders as well.
Choice E rationale:
Becoming lost in a usually familiar environment is a significant early warning sign of Alzheimer's disease. Individuals with Alzheimer's may become disoriented even in places they know well, leading to confusion and anxiety. This is a result of the disease affecting their spatial memory and navigation skills.
Correct Answer is A
Explanation
The correct answer is choice A: "Assess the client's need for assistance with ADLS."
Choice A rationale:
Safety is the top priority when caring for a client with major depressive disorder. Assessing the client's ability to perform Activities of Daily Living (ADLS) helps determine her level of functioning and any potential risks. Ensuring that the client can meet her basic self-care needs is essential for her well-being.
Choice B rationale:
Encouraging the client to create her own schedule of daily activities can be a valuable intervention, but it should come after addressing safety concerns. Choice A takes precedence as it directly relates to the client's immediate well-being.
Choice C rationale:
Teaching the client to use passive communication is not appropriate. Passive communication may hinder the client's ability to express her needs and advocate for herself. Assertive communication skills are more beneficial for her overall mental health.
Choice D rationale:
Isolating the client from unit activities may exacerbate her feelings of depression and loneliness. Encouraging engagement with appropriate unit activities and social interactions can contribute to her sense of belonging and aid in her recovery.
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