A nurse is caring for a client who is experiencing delirium. Which of the following findings should the nurse expect?
Catatonia
Echopraxia
Agraphia
Illusions
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Request that the nurses show their nursing license prior to removing your newborn from the room." While it's important to ensure that only authorized personnel handle the newborn, asking for nursing licenses is not practical and may not be feasible in a busy clinical environment. Instead, parents should be encouraged to verify the identity of staff based on hospital protocols.
B. "Leave your newborn in the bassinet in your room while you use the bathroom." Leaving the newborn unattended, even in the bassinet, is not advisable. Parents should take their newborn with them if possible or ask for help from staff to ensure the baby's safety while they are away.
C. "Alert the staff if any of your newborn's identification bands are missing." Alerting staff about missing identification bands is crucial for the safety of the newborn. Identification bands help prevent abductions and ensure that the correct infant is returned to the right mother. Parents should be vigilant and report any issues immediately.
D. "Carry your newborn back to the nursery in your arms when you need to rest." Carrying the newborn back to the nursery is not recommended for safety reasons. If the parent needs to rest, they should ask the staff to take the baby to the nursery instead, allowing for proper handling and minimizing the risk of falls or accidents.
Correct Answer is D
Explanation
A. "You should only drink 2 cups of coffee per day." While limiting coffee intake can be beneficial for some individuals with GERD, the recommendation should focus on overall caffeine intake rather than a specific amount. Caffeine can relax the lower esophageal sphincter and exacerbate symptoms, so some individuals may need to eliminate it entirely.
B. "You should eat three large meals and two snacks per day." Eating large meals can increase intra-abdominal pressure and exacerbate GERD symptoms. Instead, clients should be encouraged to eat smaller, more frequent meals throughout the day to help minimize reflux.
C. "You should lay down for 1 hour following a meal." Laying down after eating can increase the likelihood of reflux and heartburn. Clients should be advised to remain upright for at least 2 to 3 hours after meals to help prevent symptoms.
D. "You should elevate the head of the bed while sleeping." Elevating the head of the bed is a recommended practice for clients with GERD. This position can help prevent nighttime reflux by allowing gravity to keep stomach acid from rising into the esophagus, thereby reducing symptoms and improving sleep quality.
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