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 C

Explanation

A reason: Voice alteration. Voice alteration is not a common adverse effect of ECT. The procedure typically does not impact vocal cords or speech directly.

B reason: Neck pain. While discomfort and muscle soreness can occur, neck pain is not a primary or common adverse effect specifically associated with ECT.

C reason: Memory deficit. Memory deficits, particularly short-term memory loss, are a well-documented adverse effect of ECT. Clients may experience difficulty recalling recent events before and after treatment.

D reason: Headache. Headache can occur after ECT but is less concerning compared to cognitive side effects like memory deficits. Monitoring for memory changes is crucial.

A. Grandiosity. B. Flight of ideas. C. Splitting. D. Hyperactivity. E. Withdrawal.

Correct Answer is ["A","B","D"]

Explanation

A reason: Grandiosity. Grandiosity is a common behavior in manic episodes, where the individual may have an inflated sense of self-importance, abilities, or identity.

B reason: Flight of ideas. Flight of ideas involves rapidly shifting from one topic to another with little to no logical connection between them. This is a characteristic behavior during a manic episode.

C reason: Splitting. Splitting, or viewing others as all good or all bad, is more commonly associated with borderline personality disorder. It is not a typical behavior during a manic episode of bipolar disorder.

D reason: Hyperactivity. Hyperactivity, including increased energy, restlessness, and engaging in multiple activities simultaneously, is a hallmark of a manic episode.

E reason: Withdrawal. Withdrawal, or social isolation, is more characteristic of depressive episodes rather than manic episodes of bipolar disorder. During mania, individuals are more likely to be excessively social and active.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has undergone electroconvulsive therapy (ECT). The nurse should monitor the client for which of the following adverse effects of ECT?

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