A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?

Gradual onset

Impaired judgment

Difficulty swallowing

Slowed, flat speech

Answer and Explanation

The Correct Answer is B

Choice A reason: Delirium is characterized by an acute onset, typically developing over hours to a few days. It is a sudden change in mental status that differs from conditions like dementia, which have a gradual onset. Therefore, gradual onset is not a characteristic finding of delirium.

Choice B reason: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.

Choice C reason: Difficulty swallowing, or dysphagia, is not typically associated with delirium. Dysphagia is more often related to neurological conditions such as stroke, Parkinson's disease, or other disorders affecting the muscles involved in swallowing. While clients with delirium may have various physical symptoms due to underlying causes, difficulty swallowing is not a direct symptom of delirium itself.

Choice D reason: Slowed, flat speech is not a typical finding in delirium. Clients with delirium may exhibit rapid, incoherent, or disorganized speech due to their altered mental state. Slowed, flat speech is more commonly seen in conditions like depression or certain types of dementia rather than in acute delirium.

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Correct Answer is A

Explanation

Choice A reason: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety. This method reduces the risk of injury to both the client and the healthcare team.

Choice B reason: Restraint prescriptions typically need to be renewed more frequently than every 48 hours, often within 24 hours. The exact duration depends on the facility's policy and regulatory guidelines. Regular assessment of the need for restraints and timely renewal of the prescription ensure that restraints are used appropriately and only as long as necessary.

Choice C reason: Attaching restraints to the side rail of the client's bed is unsafe and inappropriate. Restraints should be attached to a non-movable part of the bed frame to prevent the client from injuring themselves if the side rail is moved. Securing restraints to a stable part of the bed ensures better control and reduces the risk of harm.

Choice D reason: While maintaining some space between the restraint and the client's skin is important to prevent circulation issues, the guideline typically suggests maintaining two fingers' breadth between the restraint and the client's skin, not one. This ensures adequate circulation and reduces the risk of injury or skin breakdown.

A. Hypoactive bowel sounds in all four quadrants. B. Client report of dry mouth. C. Constant opening and closing of mouth. D. Client report of photosensitivity.

Correct Answer is C

Explanation

Choice A reason: Hypoactive bowel sounds can indicate a variety of gastrointestinal issues, but they are not typically associated with haloperidol use. While it is important to monitor bowel sounds, it is not the priority in this context.

Choice B reason: Dry mouth is a common side effect of many medications, including haloperidol. While it can be uncomfortable for the client, it is not usually a serious concern and can be managed with hydration and other supportive measures.

Choice C reason: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.

Choice D reason: Photosensitivity is not a common side effect of haloperidol. While it is important to monitor for any new or unusual symptoms, photosensitivity is not typically associated with this medication.

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A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is monitoring a client who is receiving haloperidol. Which of the following findings is the priority to report to the provider?

Correct Answer is C

Explanation

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