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 A
Explanation
Choice A rationale:
The statement "You are feeling very depressed. I felt the same way when I decided to leave my husband." is a non-therapeutic statement that demonstrates sympathy. The nurse is sharing personal experiences, which can shift the focus from the client's feelings to the nurse's own experiences.
Choice B rationale:
The statement "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you." is a therapeutic response that offers support and empathy without diverting the focus to the nurse's experiences. The nurse's willingness to sit with the client is a positive aspect of this response.
Choice C rationale:
The statement "You seem depressed. It was a difficult decision to make. Would you like to talk about it?" is a therapeutic response that acknowledges the client's feelings, offers support, and invites further conversation. This response encourages the client to express themselves.
Choice D rationale:
The statement "I know this is a difficult time for you. Would you like medication for anxiety?" acknowledges the client's difficulties but immediately offers medication as a solution. While medication can be a valid option, it's important to prioritize open communication and emotional support before suggesting medication.
Correct Answer is D
Explanation
Choice A rationale:
Periods of elation with unusual talkativeness. Rationale: While periods of elation with unusual talkativeness can be associated with certain mental health conditions, such as bipolar disorder, they are not specific to schizophrenia. These symptoms are more indicative of mania, which is characteristic of bipolar disorder.
Choice B rationale:
Recurrent thoughts of past trauma. Rationale: Recurrent thoughts of past trauma can be associated with various mental health disorders, including post-traumatic stress disorder (PTSD), but they are not specific to schizophrenia. Schizophrenia is primarily characterized by disturbances in thought processes, perception, and behavior.
Choice C rationale:
Preoccupied with folding clothes. Rationale: Preoccupation with folding clothes is not a hallmark symptom of schizophrenia. Schizophrenia is characterized by symptoms such as hallucinations, delusions, disorganized thinking, and impaired social functioning.
Choice D rationale:
Invents words that have no meaning. Rationale: This statement is correct. Inventing words that have no meaning, also known as "neologisms," is a symptom often observed in individuals with schizophrenia. Neologisms are a manifestation of disorganized thinking and communication.
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