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 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.
Correct Answer is B
Explanation
Choice A rationale:
Bulging fontanels are a sign of increased intracranial pressure, which is an abnormal finding in newborns. The nurse should assess for other signs of neurological impairment, such as lethargy, irritability, or seizures.
Choice B rationale:
Blue hands and feet, also known as acrocyanosis, are a normal finding in newborns who are 4 hr old. This is due to immature peripheral circulation and should resolve within 24 to 48 hr.
Choice C rationale:
Generalized petechiae are a sign of bleeding disorders, infection, or trauma, which are abnormal findings in newborns. The nurse should assess for other signs of bleeding, such as bruising, hematuria, or melena.
Choice D rationale:
Flaring of the nares is a sign of respiratory distress, which is an abnormal finding in newborns. The nurse should assess for other signs of respiratory distress, such as grunting, retractions, or cyanosis.
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