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 A
Explanation
Choice A rationale:
Melanoma often originates from an existing mole or can develop as a new pigmented lesion on the skin.
Choice B rationale:
Melanoma lesions are typically asymmetrical, not symmetrical.
Choice C rationale:
Metastasis of melanoma is not rare and can occur if the disease is not diagnosed and treated early.
Choice D rationale:
Melanoma has multiple growth phases, including radial and vertical growth.
Correct Answer is B
Explanation
Choice A rationale:
Terbutaline is a medication used to inhibit uterine contractions and is not directly related to managing coarctation of the aorta.
Choice B rationale:
Coarctation of the aorta is a congenital heart defect characterized by narrowing of the aorta, which can lead to increased pressure and decreased blood flow to the lower part of the body. During labor, epidural anesthesia is often recommended for clients with coarctation of the aorta to reduce stress and pain, as well as to maintain stable blood pressure.
Choice C rationale:
Placing a client with coarctation of the aorta in a supine position during labor can worsen the obstruction of blood flow and is contraindicated. Left lateral positioning or other positions that enhance venous return are preferred.
Choice D rationale:
There is no established increased risk of preeclampsia in clients with coarctation of the aorta.
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