A nurse is assisting in the care of a client in the intensive care unit (ICU)
past medical history
illusions
change in orientation
hallucinations
Correct Answer : C,D
Rationale:
• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.
• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.
• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.
• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Polyuria: Polyuria is not a typical symptom of alcohol withdrawal. Although chronic alcohol use may affect renal function, withdrawal is more commonly associated with symptoms of autonomic hyperactivity rather than increased urine output.
B. Hypertension: Hypertension is a common manifestation of alcohol withdrawal due to autonomic nervous system overactivity. As the central nervous system adapts to the absence of alcohol, clients may experience elevated blood pressure, tremors, and agitation.
C. Constipation: Constipation is not expected during alcohol withdrawal. Clients are more likely to experience diarrhea or gastrointestinal upset due to nervous system stimulation and stress responses.
D. Bradycardia: Bradycardia is not characteristic of alcohol withdrawal. Instead, clients often present with tachycardia and other signs of heightened sympathetic activity due to the sudden absence of CNS depressant effects.
Correct Answer is B
Explanation
Rationale:
A. Anger: Anger is typically characterized by blaming others, expressing frustration, or resentment toward the situation, self, or those perceived to be responsible. It often follows denial and precedes bargaining in the stages of grief.
B. Bargaining: The statement "If only I had another day with them" reflects bargaining, a grief stage where individuals dwell on what could have been done differently to prevent the loss. This often includes hypothetical thinking or “what if” scenarios as a way to cope with the pain.
C. Denial: Denial involves refusing to accept the reality of the loss. It may manifest as disbelief or numbness, rather than expressing a desire to have more time or change past events, as seen in this client’s statement.
D. Depression: Depression in grief involves deep sadness, withdrawal, or feelings of hopelessness. While the client may be experiencing sorrow, the focus on "if only" thinking indicates bargaining more than the full emotional weight of depression.
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