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A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)

Clear and organized speech

Increased attention and focus

Fluctuating levels of consciousness

Stable and consistent cognitive function

Agitation and aggression

Answer and Explanation

Correct Answer : C,E

The correct answer is c, e.

Choice A Reason:

The statement “Clear and organized speech” is incorrect. Clients with delirium often exhibit disorganized thinking and speech. Their speech may be rambling, irrelevant, or incoherent, reflecting their fluctuating mental state. Clear and organized speech is more characteristic of a person without cognitive impairment or with stable cognitive function.

Choice B Reason:

The statement “Increased attention and focus” is incorrect. Delirium is characterized by a disturbance in attention and awareness. Clients with delirium typically have difficulty sustaining or shifting attention, which is a key diagnostic criterion. Increased attention and focus are not consistent with the presentation of delirium.

Choice C Reason:

The statement “Fluctuating levels of consciousness” is correct. One of the hallmark features of delirium is the fluctuation in the level of consciousness throughout the day3. Clients may experience periods of lucidity interspersed with confusion and disorientation. This fluctuation is a critical diagnostic indicator of delirium.

Choice D Reason:

The statement “Stable and consistent cognitive function” is incorrect. Delirium is marked by an acute change in cognitive function, which is neither stable nor consistent. Cognitive functions such as memory, orientation, and language are typically impaired and fluctuate over time. Stable cognitive function would not support a diagnosis of delirium.

Choice E Reason:

The statement “Agitation and aggression” is correct. Clients with delirium often exhibit behavioral disturbances, including agitation and aggression. These symptoms can result from the confusion and disorientation experienced during delirium. Recognizing these behavioral changes is important for the diagnosis and management of delirium.

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Correct Answer is ["A","B","D"]

Explanation

Choice A Reason:

Slowed psychomotor activity.

Slowed psychomotor activity is a hallmark of hypoactive delirium. Patients with this type of delirium often exhibit reduced physical movement and slower reaction times. This symptom can make hypoactive delirium more challenging to recognize compared to the more obvious agitation seen in hyperactive delirium.

Choice B Reason:

Impaired attention and concentration.

Impaired attention and concentration are common in all forms of delirium, including hypoactive delirium. Patients may have difficulty focusing, sustaining, or shifting attention, which can significantly impact their ability to engage in daily activities or follow conversations.

Choice C Reason:

Hallucinations and delusions.

While hallucinations and delusions can occur in delirium, they are more commonly associated with hyperactive delirium. Hypoactive delirium is characterized more by withdrawal and decreased responsiveness rather than the presence of hallucinations or delusions.

Choice D Reason:

Decreased alertness or responsiveness.

Decreased alertness or responsiveness is a key feature of hypoactive delirium. Patients may appear drowsy, lethargic, or less responsive to their environment. This can sometimes be mistaken for depression or fatigue, making it crucial to differentiate hypoactive delirium from other conditions.

Choice E Reason:

Agitation and restlessness.

Agitation and restlessness are characteristic of hyperactive delirium, not hypoactive delirium5. In hypoactive delirium, patients are more likely to be withdrawn and less responsive rather than agitated or restless.

A. Autonomy B. Justice C. Beneficence D. Veracity

Correct Answer is A

Explanation

Choice A Reason:

The statement “Autonomy” is correct. Autonomy is the ethical principle that respects an individual’s right to make their own decisions and act on their own values. By allowing clients to choose whether or not to attend group therapy, the unit manager is preserving the clients’ autonomy. This approach acknowledges the clients’ ability to make informed decisions about their own treatment and respects their personal preferences and values1. Autonomy is a fundamental principle in healthcare, emphasizing the importance of respecting patients’ rights to self-determination.

Choice B Reason:

The statement “Justice” is incorrect. Justice refers to the ethical principle of treating individuals fairly and equitably. While justice is an important consideration in healthcare, the policy of allowing clients to choose whether or not to attend group therapy is more directly related to respecting their autonomy rather than ensuring equitable treatment. Justice would be more relevant in ensuring that all clients have equal access to group therapy sessions and resources.

Choice C Reason:

The statement “Beneficence” is incorrect. Beneficence is the ethical principle that involves acting in the best interest of the client and promoting their well-being. While encouraging group therapy can be seen as an act of beneficence, the specific policy of allowing clients to choose whether or not to attend is more aligned with respecting their autonomy. Beneficence focuses on doing good for the client, whereas autonomy emphasizes the client’s right to make their own choices.

Choice D Reason:

The statement “Veracity” is incorrect. Veracity refers to the ethical principle of truthfulness and honesty in interactions with clients. While veracity is crucial in maintaining trust and transparency in the therapeutic relationship, the policy of allowing clients to choose whether or not to attend group therapy is primarily about respecting their autonomy. Veracity would be more relevant in ensuring that clients are fully informed about the benefits and potential risks of group therapy.

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A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing assessment data collected from a post-operative patient. What assessment findings would serve as cues that the client may be experiencing hypoactive delirium? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager’s policy preserve?

Correct Answer is A

Explanation

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