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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.)

A.

Agitation

B.

Slow, flat speech

C.

Visual hallucinations

D.

Confusion

E.

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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Related Questions

Correct Answer is B

Explanation

Choice A rationale:

Abdominal cramps are not typically associated with opioid intoxication. Choice B rationale:

Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.

Choice C rationale:

Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).

Choice D rationale:

Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.

Correct Answer is A

Explanation

Choice A rationale:

Low dietary intake of fiber is a significant risk factor for diverticular disease. A diet low in fiber can lead to constipation and increased pressure in the colon, contributing to the formation of diverticula.

Choice B rationale:

Prolonged use of steroids is not a primary risk factor for diverticular disease.

Choice C rationale:

Insufficient intake of protein is not a significant risk factor for diverticular disease.

Choice D rationale:

Family history of gallbladder disease is not directly associated with an increased risk of diverticular disease.

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