A nurse is assessing a client who has delirium as a result of sepsis. Which of the following manifestations should the nurse expect? (Select all that apply.)

Slow speech.

Rapid mood changes.

Hallucinations.

Unaltered level of consciousness.

Restlessness.

Answer and Explanation

Correct Answer : B,C,E

A reason: Slow speech. Slow speech is not typically associated with delirium. Clients with delirium often exhibit rapid and disorganized speech rather than slowed speech patterns.

B reason: Rapid mood changes. Rapid mood changes are common in delirium. Clients may quickly shift from calm to agitated or from happy to irritable, reflecting the fluctuating nature of their cognitive status.

C reason: Hallucinations. Hallucinations, particularly visual or auditory, are a common symptom of delirium. Clients may see or hear things that are not present, contributing to their confusion and distress.

D reason: Unaltered level of consciousness. Delirium is characterized by altered levels of consciousness, not unaltered. Clients may experience fluctuating alertness, from drowsiness to hyperactivity.

E reason: Restlessness. Restlessness and agitation are hallmark symptoms of delirium. Clients may become physically restless, unable to sit still, and exhibit purposeless movements.

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Correct Answer is B

Explanation

A reason: Flight of ideas. Flight of ideas is characterized by rapid shifts from one topic to another, often with a logical connection between the topics. The client's statement does not exhibit this pattern and is more disorganized.

B reason: Word salad. Word salad refers to a jumble of words and phrases that are incoherent and lack meaningful connections. The client's statement, "Walk tall broom short dog bell," fits this description, as it is a nonsensical combination of words.

C reason: Neologisms. Neologisms are newly created words that have meaning only to the person who uses them. The client's statement does not include any new or invented words, making this choice inappropriate.

D reason: Clang associations. Clang associations involve the use of words based on their sound rather than their meaning, often rhyming or having a similar beginning sound. The client's statement does not exhibit this pattern.

A. Hallucinations. B. Depression. C. Delusions. D. Catatonia. E. Tinnitus.

Correct Answer is ["B","C"]

Explanation

A reason: Hallucinations. Hallucinations can be distressing and are associated with various mental health conditions, but they are not a direct indicator of suicide risk without other contributing factors.

B reason: Depression. Depression is a significant risk factor for suicide. Clients experiencing persistent sadness, hopelessness, and a lack of interest in life are at a higher risk for attempting suicide.

C reason: Delusions. Delusions, particularly those that are paranoid or nihilistic, can contribute to feelings of hopelessness and despair, increasing the risk of suicide attempts.

D reason: Catatonia. Catatonia involves motor immobility and behavioral abnormality. While it is a serious condition requiring treatment, it is not a direct indicator of suicide risk without other contributing factors.

E reason: Tinnitus. Tinnitus, or ringing in the ears, is not associated with an increased risk of suicide. It is a physical symptom that does not directly influence suicidal behavior.

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A nurse is assessing a client who has delirium as a result of sepsis. Which of the following manifestations should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care facility is assessing a client who has schizophrenia. The client states, "Walk tall broom short dog bell." The nurse should document the client's speech as which of the following speech patterns?

Correct Answer is B

Explanation

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Correct Answer is ["B","C"]

Explanation

A nurse is assessing a client who has delirium as a result of sepsis. Which of the following manifestations should the nurse expect? (Select all that apply.)

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