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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 B

Explanation

Choice A Reason:

Somatic.

Somatic delusions involve a false belief that there is something physically wrong with one’s body, such as having a serious illness or a physical defect. In this scenario, the client’s belief that the food is poisoned does not relate to their own body but rather to an external threat, making somatic delusions an incorrect classification.

Choice B Reason:

Persecutory.

This is the correct response. Persecutory delusions, also known as paranoid delusions, involve the belief that one is being targeted, harassed, or conspired against. The client’s statement that the staff is poisoning the food reflects a belief that they are being harmed or targeted, which is characteristic of persecutory delusions. These types of delusions are the most common in schizophrenia and often involve themes of being persecuted or plotted against.

Choice C Reason:

Erotomanic.

Erotomanic delusions involve the false belief that another person, often someone of higher status, is in love with the individual. This type of delusion is not relevant to the client’s statement about the food being poisoned, as it does not involve any romantic or affectionate themes.

Choice D Reason:

Grandiose.

Grandiose delusions involve an inflated sense of one’s own importance, power, knowledge, or identity. The client’s belief about the food being poisoned does not reflect an exaggerated sense of self-importance or power, making grandiose delusions an incorrect classification for this scenario.

A. “It is okay to eat dessert with my dinner every night.” B. “I have less to worry about because I am a female.” C. “I can speak with my healthcare provider about genetic testing.” D. “I need to make sure to take my blood pressure medication daily.” E. “I do not have time in my schedule to add a daily walk.”

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

Explanation

Choice A Reason:

The statement “It is okay to eat dessert with my dinner every night” indicates a need for re-teaching. Diet plays a significant role in the risk of developing Alzheimer’s disease. Consuming high amounts of sugar and unhealthy fats can increase the risk of developing conditions like diabetes and cardiovascular disease, which are linked to a higher risk of Alzheimer’s. A balanced diet, such as the Mediterranean or MIND diet, which emphasizes fruits, vegetables, whole grains, and healthy fats, is recommended to reduce the risk.

Choice B Reason:

The statement “I have less to worry about because I am a female” is incorrect and indicates a need for re-teaching. In fact, women are at a higher risk of developing Alzheimer’s disease compared to men. This increased risk is partly due to women living longer than men, but even after accounting for longevity, women still have a higher incidence of Alzheimer’s. Therefore, it is crucial for females to be aware of their risk and take preventive measures.

Choice C Reason:

The statement “I can speak with my healthcare provider about genetic testing” does not indicate a need for re-teaching. Genetic testing can provide valuable information about one’s risk for Alzheimer’s disease, especially if there is a family history of the condition. While routine genetic testing is not generally recommended for everyone, discussing it with a healthcare provider can help individuals understand their risk and make informed decisions about their health.

Choice D Reason:

The statement “I need to make sure to take my blood pressure medication daily” is correct and does not indicate a need for re-teaching. Controlling blood pressure is crucial in reducing the risk of Alzheimer’s disease. High blood pressure, particularly in midlife, is a significant risk factor for cognitive decline and Alzheimer’s. Therefore, taking blood pressure medication as prescribed is an important preventive measure.

Choice E Reason:

The statement “I do not have time in my schedule to add a daily walk” indicates a need for re-teaching. Regular physical activity is one of the most effective ways to reduce the risk of Alzheimer’s disease. Exercise improves blood flow to the brain, reduces inflammation, and promotes the growth of new brain cells. Incorporating physical activity, such as a daily walk, into one’s routine is essential for maintaining cognitive health and reducing the risk of Alzheimer’s.

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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 caring for a client who has schizophrenia. The client is in the dayroom and shouting at other clients, stating, “Do not eat the food here. The staff is poisoning the food!” The nurse should document that the client is experiencing which type of delusion?

Correct Answer is B

Explanation

A client was recently diagnosed with mild Alzheimer’s disease. Which of the statements shared by the client’s child about their risk for Alzheimer’s disease indicates the need for re-teaching? (Select all that apply.)

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

Explanation

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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.)

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