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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Disorganized speech is a hallmark symptom of acute mania in bipolar disorder. Clients may exhibit pressured speech, tangentiality, and flight of ideas, reflecting the heightened energy and cognitive disruptions associated with manic episodes.

Choice B rationale: Reporting auditory hallucinations, such as voices telling the client to write a novel, is more indicative of a psychotic disorder rather than acute mania in bipolar disorder. Mania typically involves elevated mood and activity levels, not hallucinations.

Choice C rationale: Weight gain reported by the spouse is not specific to acute mania. While changes in appetite and weight can occur in bipolar disorder, they are not defining features of manic episodes, which are characterized by heightened mood and activity.

Choice D rationale: Being dressed in all black does not specifically indicate acute mania. Mania is characterized by mood disturbances and increased activity levels rather than specific choices in clothing color, which can vary widely among individuals.

A. Plan a therapeutic diet for the client. B. Provide a structured environment for the client. C. Assess client's nutritional status. D. Request a mental health consult.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Planning a therapeutic diet is essential for the client's recovery. However, it is not the first priority. Understanding the client's nutritional needs and current deficiencies should come before creating a diet plan.

Choice B rationale: Providing a structured environment is important to ensure the client follows the treatment plan and receives the appropriate support. However, it comes after assessing the client's current state and needs.

Choice C rationale: Assessing the client's nutritional status is the first priority because it provides critical information about the client's current health and guides all other aspects of care. Without knowing the client's nutritional status, it is challenging to make informed decisions about her treatment plan.

Choice D rationale: Requesting a mental health consult is important, especially given the client's belief that she is fat and the significant weight loss. However, before addressing her psychological needs, the nurse must understand her physical health status to provide comprehensive care.

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A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?

Correct Answer is A

Explanation

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is C

Explanation

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