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 C

Explanation

A behavioral contract is a written agreement between the client and the nurse that specifies the desired and undesired behaviors and the rewards and penalties for each. A client who has antisocial personality disorder may exhibit impulsive, aggressive, and manipulative behaviors that disrupt the therapeutic milieu and interfere with treatment goals. Decreasing the number of verbal outbursts is a measurable and realistic goal that can improve the client's interpersonal skills and reduce conflict.

A. The client states that he is unable to eat more than once a day. B. The client frequently recalls negative experiences that occurred during his marriage. C. The client relates that he is angry that the provider did not save his partner's life. D. The client says he feels guilty about not spending more time with his partner.

Correct Answer is A

Explanation

The nurse's priority is to address the client's physical needs, such as nutrition and hydration, which are essential for survival and recovery. The client who is unable to eat more than once a day is at risk for malnutrition, dehydration, and electrolyte imbalance, which can lead to serious complications. The other findings indicate emotional distress and grief, which are also important to address, but not as urgent as the client's physical health.

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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

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Explanation

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Correct Answer is A

Explanation

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