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:
Somatropin can affect glucose metabolism and may lead to hypoglycemia. Parents should be aware of this potential side effect and monitor their child's blood sugar levels.
Choice B rationale:
Somatropin is usually administered via injection, not under the tongue.
Choice C rationale:
Ringing in the ears is not a common side effect of somatropin.
Choice D rationale:
Monitoring height monthly is important, but explaining the potential for hypoglycemia is more relevant to the immediate safety of the child.
Correct Answer is A
Explanation
Choice A rationale:
Poorly controlled blood sugar levels can lead to fetal overgrowth (macrosomia), which increases the risk of a large baby during delivery.
Choice B rationale:
High blood sugar levels after delivery are not specific to babies born to mothers with type 1 diabetes.
Choice C rationale:
Insulin dosage requirements often increase during the second and third trimesters due to insulin resistance, not decrease.
Choice D rationale:
The risk of ketoacidosis is not typically increased in the first trimester; rather, the focus is on controlling blood sugar levels to minimize risks to the developing fetus.
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