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

Agitation

Slow, flat speech

Visual hallucinations

Confusion

Rapid mood swings

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.

Choice B rationale:

Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.

Choice C rationale:

Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.

Choice D rationale:

Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.

Choice E rationale:

Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.

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Correct Answer is D

Explanation

Choice A rationale:

Monitoring for hearing loss is not a specific action for primary syphilis. Hearing loss can occur in later stages of syphilis.

Choice B rationale:

Contact precautions are not typically required for primary syphilis, as it is primarily transmitted through sexual contact.

Choice C rationale:

Antiviral medications are not used to treat syphilis. Antibiotics are the primary treatment.

Choice D rationale:

Syphilis is a sexually transmitted infection that is required to be reported to the public health department for tracking and control.

A. Hgb 13 g/dl B. BUN 8 mg/dL C. Bilirubin 1.8 mg/dL D. Hct 38%

Correct Answer is C

Explanation

Choice A rationale:

A hemoglobin level of 13 g/dL is within the normal range and is not specifically indicative of HELLP syndrome.

Choice B rationale:

A blood urea nitrogen (BUN) level of 8 mg/dL is within the normal range and is not typically associated with HELLP syndrome.

Choice C rationale:

Elevated bilirubin levels are a characteristic feature of HELLP syndrome, which involves liver dysfunction.

Choice D rationale:

A hematocrit level of 38% is within the normal range and is not specifically indicative of HELLP syndrome.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has primary syphilis. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory results of a client who has HELLP syndrome. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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