A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?
Hallucinations
Agnosia
Bradycardia
Aphasia
The Correct Answer is A
A.
A. Hallucinations - Delirium can cause perceptual disturbances such as hallucinations, where the client perceives things that are not actually present.
B. Agnosia - Agnosia refers to the inability to recognize familiar objects, which is not typically associated with delirium.
C. Bradycardia - Delirium is not typically associated with bradycardia; it may actually be associated with tachycardia due to the physiological stress response.
D. Aphasia - Aphasia refers to the loss of ability to understand or express speech, which is not typically associated with delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.
B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.
C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.
D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.
Correct Answer is B
Explanation
A. Crepitus is not typically associated with right ventricular heart failure; it may indicate subcutaneous emphysema or air leakage into the tissues.
B. Right ventricular heart failure often leads to elevated pulmonary artery pressure due to increased pressure in the pulmonary circulation.
C. Hepatosplenomegaly may occur in congestive heart failure but is not specific to right ventricular heart failure.
D. Confusion may occur in severe cases of heart failure due to decreased cerebral perfusion, but it is not specific to right ventricular heart failure.
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