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 C
Explanation
The correct answer is choice C. Suspended from school several times in the past year.
Choice A rationale:
The client's father's recent death (Choice A) is not a typical expected assessment finding of conduct disorder. While emotional disturbances can be associated with conduct disorder, the primary characteristics involve behavioral issues rather than reactions to significant life events.
Choice B rationale:
Adhering strictly to routines (Choice B) is not a common expected assessment finding of conduct disorder. Conduct disorder is characterized by patterns of defiant and disruptive behaviors, not necessarily a rigid adherence to routines.
Choice C rationale:
Suspended from school several times in the past year (Choice C) aligns with the expected assessment findings of conduct disorder. Conduct disorder often involves aggressive behavior towards others, violation of rules, and disregard for the rights of others, which can lead to disciplinary actions such as school suspensions.
Choice D rationale:
Experiencing frequent facial tics (Choice D) is not a typical expected assessment finding of conduct disorder. Facial tics are associated with conditions like Tourette's syndrome or other tic disorders, not conduct disorder.
Correct Answer is B
Explanation
Choice A rationale:
Bizarre behavior is not a negative symptom of schizophrenia but rather a positive symptom. Positive symptoms involve an excess or distortion of normal functioning and include hallucinations, delusions, and disorganized speech or behavior. Bizarre behavior falls under the category of disorganized behavior, which is a positive symptom.
Choice B rationale:
Waxy flexibility is a characteristic of negative symptoms in schizophrenia. Negative symptoms involve a reduction or loss of normal functioning and include behaviors like social withdrawal, reduced emotional expression, and decreased motivation. Waxy flexibility refers to the phenomenon where a person with schizophrenia can be molded into different positions and maintain those positions for an extended period. This rigidity is a manifestation of reduced spontaneous movement, which is a negative symptom.
Choice C rationale:
Somatic delusions are a type of positive symptom seen in schizophrenia. These delusions involve false beliefs about one's body, health, or bodily functions. They are not negative symptoms, which are characterized by deficits in normal functioning.
Choice D rationale:
Illogicality is related to disorganized thinking, which is a positive symptom of schizophrenia. Individuals experiencing disorganized thinking may have difficulty organizing their thoughts coherently and logically, leading to speech that is difficult to follow. Negative symptoms, on the other hand, involve a decrease in normal functioning and do not pertain to logical coherence.
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