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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Comfrey is not commonly recommended as an herbal supplement for menopausal symptoms. It has been associated with potential liver toxicity.
Choice B rationale:
Ginkgo biloba is often used to improve cognitive function and circulation but is not typically used to address menopausal symptoms.
Choice C rationale:
Black cohosh is an herbal supplement that is commonly used by middle-aged women to help alleviate symptoms related to menopause, such as hot flashes and mood swings. Black cohosh may also have some benefits for bone health and cardiovascular health. However, black cohosh may also have some side effects and interactions with other medications, so the nurse should advise the women to consult their health care providers before taking it.
Choice D rationale:
Garlic is not typically used as an herbal supplement to manage menopausal symptoms; it is more commonly known for its potential cardiovascular benefits.
Correct Answer is D
Explanation
Choice A rationale:
An adventitious crisis is a crisis resulting from an external event such as a natural disaster or crime.
Choice B rationale:
Psychopathologic crises involve individuals with preexisting mental health conditions experiencing acute exacerbations.
Choice C rationale:
A psychiatric emergency involves a sudden onset of severe behavioral symptoms that require immediate intervention.
Choice D rationale:
A situational crisis arises from an unexpected life event, such as injury, illness, or loss of independence, which can disrupt a person's normal routine and coping mechanisms.
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