A nurse is caring for a client who has delirium.
Which of the following findings should the nurse expect?
Gradual onset.
Difficulty swallowing.
Slowed, flat speech.
Impaired judgment.
The Correct Answer is D
Choice A rationale
Delirium is characterized by an acute and fluctuating onset of disturbances in attention and cognition that develop over a short period, typically hours to days. A gradual onset is more characteristic of conditions like dementia rather than the rapid changes seen in delirium.
Choice B rationale
Difficulty swallowing, or dysphagia, is not a primary characteristic of delirium. While neurological conditions can cause both delirium and dysphagia, difficulty swallowing is not a core diagnostic criterion for delirium itself. Other conditions should be considered for this specific finding.
Choice C rationale
Slowed, flat speech is more commonly associated with depression or neurological conditions rather than delirium. Delirium typically presents with disorganized thinking and speech that may be rapid, incoherent, or difficult to follow, reflecting the altered level of consciousness and attention.
Choice D rationale
Impaired judgment is a key feature of delirium. The disturbance in attention and cognition affects the ability to process information, think clearly, and make sound decisions. This can manifest as poor understanding of situations, impulsive behavior, and an inability to appreciate potential consequences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A need for only a couple of hours of sleep each night could suggest mania, a symptom associated with bipolar disorder, rather than schizophrenia. Individuals with schizophrenia often experience sleep disturbances, but this specific statement is more indicative of a manic episode.
Choice B rationale
Difficulty remembering where things are placed can be a symptom of various conditions, including normal aging, stress, depression, or cognitive impairments. While cognitive deficits can occur in schizophrenia, this statement alone is not a strong indicator of the disorder's core features.
Choice C rationale
The statement "I won't eat because I know that the food has been poisoned" is a paranoid delusion, a positive symptom commonly seen in schizophrenia. Delusions are fixed, false beliefs that are not based in reality and are a hallmark feature of psychotic disorders like schizophrenia.
Choice D rationale
Counting stairs to feel more in control could be a mild compulsion or a coping mechanism for anxiety. While anxiety can co-occur with schizophrenia, this behavior itself is not a primary diagnostic criterion for the disorder.
Correct Answer is B
Explanation
Choice A rationale
Liver enzymes (such as ALT and AST) are primarily monitored for medications known to cause liver toxicity. While lithium can have various side effects, it is not typically associated with significant liver damage requiring routine monitoring of liver enzyme levels. Normal ranges for ALT are typically 7 to 55 units per liter (U/L) for men and 5 to 40 U/L for women, and for AST are typically 10 to 40 U/L for men and 9 to 32 U/L for women.
Choice B rationale
Lithium is a mood stabilizer with a narrow therapeutic range, and its levels are closely linked to sodium balance in the body. Hyponatremia (low sodium levels) can increase the risk of lithium toxicity because the kidneys reabsorb lithium in an attempt to compensate for the sodium loss. Therefore, regular monitoring of serum sodium levels is crucial to ensure lithium remains within the therapeutic range (typically 0.6 to 1.2 mEq/L for maintenance) and to prevent toxicity. Normal serum sodium levels are generally 135 to 145 mEq/L.
Choice C rationale
Uric acid levels are primarily monitored in conditions like gout or kidney disease, or as a side effect of certain medications affecting purine metabolism. Lithium does not typically have a significant impact on uric acid levels requiring routine monitoring. Normal uric acid levels are typically 3.5 to 7.2 mg/dL for men and 2.6 to 6.0 mg/dL for women.
Choice D rationale
Erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation in the body. While lithium can have various effects, it is not typically associated with significant changes in ESR that would necessitate routine monitoring. Normal ESR values are generally 0 to 15 mm/hr for men and 0 to 20 mm/hr for women. .
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