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

The nurse should collaborate with the client to set realistic and achievable goals for weight gain and recovery. This can help increase the client's sense of control and motivation. The other options are not appropriate because they do not involve the client in the decision-making process, and they may increase the client's resistance or anxiety.

A. "The client is just like my brother who finally overcame his habit." B. "The client asked me to go on a date with him, but I refused." C. "The client generally shares his feelings during group therapy sessions." D. "The client needs to accept responsibility for his substance use."

Correct Answer is A

Explanation

Countertransference occurs when a staff member projects their own feelings or experiences onto a client. In this case, the staff nurse is comparing the client to their brother, which can interfere with objective and empathetic care.

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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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