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 B

Explanation

Choice A rationale:

Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.

Choice B rationale:

Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.

Choice C rationale:

Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.

Choice D rationale:

Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.

A. Observe the client for 1 hr following meals. B. Encourage the client to gain 2.27 kg (5 lb) per week. C. Allow the client to exercise for less than 1 hr per day. D. weigh the client in the morning every other day. E. weigh the client in the morning every other day.

Correct Answer is A

Explanation

Choice A rationale:

Monitoring the client for a period of time after meals helps prevent behaviors such as purging or excessive exercise, which individuals with anorexia nervosa might engage in to compensate for food intake.

Choice B rationale:

Encouraging a specific weight gain is not the initial priority. Weight restoration should be approached carefully and gradually to avoid refeeding syndrome.

Choice C rationale:

Allowing the client to exercise for less than 1 hr per day is a potential intervention, but the priority is to observe the client after meals to prevent harmful behaviors.

Choice D rationale:

Weighing the client in the morning every other day is an important monitoring step, but it is not the initial intervention during admission.

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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 caring for a client who is suspected to have developed sensitivity to latex. Which of the following interventions should the nurse plan to implement?

Correct Answer is B

Explanation

A nurse is developing a plan of care while admitting a client who has anorexia nervosa. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

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