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:
The statement "I know that men who are abusers gain power through intimidation." is accurate and aligned with the understanding of domestic violence dynamics. Abusers often use intimidation tactics to exert control over their victims, perpetuating a cycle of power and control.
Choice B rationale:
The statement "I have heard that abusers think of themselves as important and have high self-esteem." needs clarification. This statement is not entirely accurate. Abusers may display a façade of high self-esteem, but beneath it, they often have deep-seated insecurities. It's important to highlight that abusive behavior stems from a desire to control and dominate, rather than genuine self-worth.
Choice C rationale:
The statement "I know that abusers lack social supports and social skills." is inaccurate. Abusers can have social supports and social skills. Domestic violence is not solely determined by the lack of social skills or support; it is a complex issue rooted in power dynamics and learned behaviors.
Choice D rationale:
The statement "I have heard that abusers try to keep their partner isolated from others." is accurate and aligned with the understanding of domestic violence dynamics. Abusers frequently isolate their partners to maintain control over them, making it difficult for victims to seek help or support from others.
Correct Answer is A
Explanation
Choice A rationale:
Similar to the explanation in , this statement requires intervention. It reflects a judgmental and prescriptive approach, which is not conducive to a therapeutic conversation. It implies that the nurse knows what the client should do, undermining the client's autonomy and self-discovery process.
Choice B rationale:
Recognizing that relationship difficulties are stressful and require effort to resolve is a valid and supportive statement. It acknowledges the challenges the client is facing and does not impose a specific solution.
Choice C rationale:
Suggesting the development of a communication plan is a proactive and therapeutic response. It empowers the client to work collaboratively toward improving their marital situation.
Choice D rationale:
Encouraging the client to share more about their concerns promotes open communication and allows the nurse to better understand the client's perspective. This response is client-centered and supportive.
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