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

Valproate (Depakote).

Carbamazepine (Tegretol).

Choice A rationale:

Lithium is a mood stabilizer commonly used to treat bipolar disorder. It helps to regulate mood swings, prevent manic episodes, and reduce the risk of depressive episodes.

Choice B rationale:

Donepezil is not used to treat bipolar disorder. It is an acetylcholinesterase inhibitor primarily used to treat symptoms of Alzheimer's disease.

Choice C rationale:

Valproate (Depakote) is another mood stabilizer used in the treatment of bipolar disorder. It can help manage both manic and depressive episodes, as well as prevent future mood swings.

Choice D rationale:

Carbamazepine (Tegretol) is an anticonvulsant medication that also has mood-stabilizing properties. It is often prescribed for individuals with bipolar disorder, especially those who do not respond well to lithium.

Choice E rationale:

Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. It is not a primary medication choice for bipolar disorder.

A. Verbalize disapproval of the client's substance abuse. B. Maintain a nonjudgmental attitude. C. Offer sympathetic support. D. Avoid displaying an emotional response.

Correct Answer is B

Explanation

The correct answer is choice B: Maintain a nonjudgmental attitude.

Choice A rationale:

Verbalize disapproval of the client's substance abuse. Expressing disapproval can create a negative environment and hinder the therapeutic relationship. Judgmental attitudes can make clients feel defensive and less likely to open up about their struggles.

Choice B rationale:

Maintain a nonjudgmental attitude. Maintaining a nonjudgmental attitude is crucial in building trust and rapport with clients. It creates an environment where clients feel safe discussing their issues without fear of criticism. A nonjudgmental attitude encourages open communication and helps the nurse gather relevant information to provide appropriate care.

Choice C rationale:

Offer sympathetic support. While offering support is important, sympathy might inadvertently convey pity or enable the client's behavior. Empathy, where the nurse understands and shares the client's feelings without judgment, is more effective in building a therapeutic relationship.

Choice D rationale:

Avoid displaying an emotional response. While it's important for the nurse to maintain professionalism, avoiding any emotional response might come across as cold or detached. Expressing appropriate empathy and emotions can actually enhance the therapeutic relationship.

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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

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Explanation

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Correct Answer is B

Explanation

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