A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?

The client has a flat affect.

The client's manifestations developed suddenly.

The client's speech is slow and repetitious.

The client is unable to recognize objects.

Answer and Explanation

The Correct Answer is B

Delirium is an acute confusional state that can have various causes, such as infection, medication, or metabolic imbalance. It is characterized by a sudden onset of altered mental status, fluctuating levels of consciousness, disorientation, and perceptual disturbances.

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Correct Answer is B

Explanation

A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.

B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.

C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.

D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.

A. Recreational therapist B. Occupational therapist C. Clinical nurse specialist D. Social worker

Correct Answer is D

Explanation

This team member can help the client find appropriate and affordable housing options, as well as connect them with community resources and support services. The other team members have different roles in the client's care, such as providing recreational activities, occupational skills, or specialized nursing interventions.

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A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Correct Answer is B

Explanation

Who should the nurse contact to assist the client with housing placement for discharge?

Correct Answer is D

Explanation

A nurse is assessing a client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during this situational crisis?

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A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

What is the priority finding to report to other disciplines for a client who has major depressive disorder?

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