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

Catatonia

Echopraxia

Agraphia

Illusions

Answer and Explanation

The Correct Answer is D

A. Catatonia. Catatonia involves significant motor disturbances such as rigidity, mutism, or excessive movement, commonly seen in schizophrenia or severe mood disorders. Delirium is characterized by acute confusion, fluctuating attention, and perceptual disturbances rather than motor abnormalities.
B. Echopraxia. Echopraxia is the involuntary repetition of another person’s movements, often linked to schizophrenia and autism spectrum disorders. Delirium primarily presents with disorientation, altered consciousness, and hallucinations rather than repetitive motor behaviors.
C. Agraphia. Agraphia is the loss of the ability to write due to neurological conditions like stroke or dementia. Delirium is an acute and reversible cognitive disturbance that affects attention and perception but does not typically result in isolated language deficits.
D. Illusions. Illusions involve the misinterpretation of real stimuli, such as mistaking a cord for a snake, and are common in delirium. This occurs due to the client's fluctuating mental status, impaired sensory perception, and difficulty distinguishing reality from distorted perceptions.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Remove the tape by pulling from the center of the dressing. Tape should be removed by pulling toward the wound rather than from the center to avoid skin trauma and unnecessary disruption to the healing tissue. Pulling from the center can increase discomfort and damage surrounding skin.
B. Clean the wound from the center to the outer edges. Cleaning from the center outward prevents the introduction of microorganisms from the surrounding skin into the wound, reducing the risk of further infection. This technique follows the principle of working from the cleanest area to the least clean.
C. Moisten the dressing before removal. A wet-to-dry dressing is meant to adhere to necrotic tissue and debris, which is then removed when the dry dressing is taken off. Moistening it before removal defeats this purpose by softening the dressing, reducing its effectiveness in debriding the wound.
D. Wear sterile gloves to remove the dressing. Clean gloves are appropriate for removing a contaminated dressing. Sterile gloves are necessary for applying the new dressing to maintain an aseptic environment. Using sterile gloves for removal is unnecessary and does not improve infection control.

A. Asking the client to point their toes before applying the stockings B. Turning the stockings inside out before applying them C. Ensuring that creases in the stockings are on the front of the client's legs D. Applying the stockings before the client gets out of bed

Correct Answer is C

Explanation

A. Asking the client to point their toes before applying the stockings is an appropriate action. This maneuver helps to flex the foot, making it easier to apply the stockings and ensuring they fit properly without causing discomfort.
B. Turning the stockings inside out before applying them is an acceptable practice as it can make them easier to put on and ensure they fit well on the client’s leg. This action does not require intervention.
C. Ensuring that creases in the stockings are on the front of the client's legs requires intervention. The stockings should be applied smoothly and without creases to prevent pressure areas, which could lead to skin breakdown or complications. Creases should be avoided on any part of the stockings that may cause discomfort or impede circulation.
D. Applying the stockings before the client gets out of bed is appropriate. Antiembolic stockings are often applied while the client is in bed to prevent complications associated with immobility, such as deep vein thrombosis (DVT). This action supports patient safety and comfort.

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

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