A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F).
A client attempts to climb out of bed and repeatedly states she must get home.
A client refuses to get out of bed and has no motivation to attend to daily hygiene.
A client wants to know the current time while there is a clock on the wall.
The Correct Answer is B
The correct answer is choice B.
Choice A rationale:
A client requesting extra blankets due to a room temperature discrepancy is not indicative of delirium. This behavior may simply stem from feeling cold, which is a logical response to a temperature below the client's comfort level.
Choice B rationale:
A client attempting to climb out of bed and repeatedly stating a need to get home is a manifestation of delirium. Delirium is characterized by sudden disturbances in consciousness and cognitive function, leading to confusion and altered perception. The client's behavior suggests a disoriented state and a distorted perception of reality.
Choice C rationale:
A client refusing to get out of bed and lacking motivation for daily hygiene might not necessarily indicate delirium. These symptoms could be related to other factors, such as depression or physical discomfort, which are not specific to delirium.
Choice D rationale:
A client wanting to know the current time when there is a visible clock on the wall doesn't indicate delirium. It might just reflect the client's desire to know the time, which is a common behavior and doesn't directly relate to cognitive disturbances associated with delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Reviewing the client's toxicology laboratory report is not the priority action in this situation. While assessing toxicology can provide valuable information, the immediate concern is the client's safety due to their admission of thoughts of self-harm with a plan. Toxicology can be relevant but addressing the immediate risk takes precedence.
Choice B rationale:
Initiating suicide precautions is the priority action in this case. The client's admission of thoughts of self-harm with a plan indicates a high risk for suicide. Suicide precautions involve closely monitoring the client, removing any potential means of self-harm, and providing a safe environment. Addressing the client's immediate safety is of utmost importance.
Choice C rationale:
Making a contract with the client for eating behavior is not the priority action in this situation. While eating behavior might be a concern for some individuals with borderline personality disorder, depression, and substance abuse, the client's current statement about self-harm takes precedence. Ensuring the client's safety comes before addressing other aspects of their care.
Choice D rationale:
Administering the Hamilton Depression Scale is not the priority action in this scenario. While assessing the severity of the client's depression is important, the immediate concern is their safety due to the expressed thoughts of self-harm. Once the client's safety is ensured, further assessment and evaluation can take place.
Correct Answer is D
Explanation
The correct answer is D:
Choice A reason: “If a dose is missed, double the next dose of medication.” This statement is incorrect. Doubling up on a dose can lead to an overdose and serious side effects. Patients are advised to take the missed dose as soon as they remember unless it’s almost time for the next dose.
Choice B reason: “This medication may increase your blood pressure.” Alprazolam is known to have a sedative effect, which can lower blood pressure rather than increase it. Therefore, this statement is not typically accurate.
Choice C reason: “Do not eat aged cheeses while taking this medication.” This dietary restriction is associated with monoamine oxidase inhibitors (MAOIs), which are a different class of medications used to treat depression. Alprazolam does not interact with tyramine-rich foods like aged cheeses, so this statement is not applicable.
Choice D reason: “Use a dependable form of contraception while taking this medication.” Alprazolam falls under FDA Pregnancy Category D, which means there is positive evidence of human fetal risk, but the potential benefits may warrant use in pregnant women despite the risks. Therefore, it is important to use reliable contraception to prevent pregnancy while taking this medication.
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