A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?
Sleep deprivation
Normal signs of aging
Dementia
Delirium
The Correct Answer is D
Choice A Reason:
Sleep deprivation is incorrect. While sleep deprivation can cause confusion and disorientation, it is less likely to cause abrupt onset of altered mental status and hallucinations. Sleep deprivation typically results in gradual cognitive decline and fatigue rather than sudden changes.
Choice B Reason:
Normal signs of aging is incorrect. Normal aging can involve some cognitive decline, but it does not typically cause sudden and severe symptoms like hallucinations and significant disorientation. These symptoms are more indicative of an acute condition.
Choice C Reason:
Dementia is incorrect. Dementia involves a gradual decline in cognitive function over time and does not typically present with sudden onset of symptoms. While dementia can include hallucinations and disorientation, these symptoms usually develop progressively.
Choice D Reason:
Delirium is correct. Delirium is characterized by a sudden onset of confusion, disorientation, and changes in mental status. It is often triggered by acute medical conditions such as infections, including UTIs. Elderly patients are particularly susceptible to delirium, which can include symptoms like hallucinations and severe confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Apple juice is an appropriate choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without putting strain on the digestive system. Apple juice is easily digestible and does not contain any solid particles that could be problematic for a client recovering from abdominal surgery.
Choice B reason: Smoothies can be included in a full liquid diet as long as they are well-blended and do not contain any solid chunks. Smoothies can provide essential nutrients and calories, which are important for recovery. They can be made with fruits, vegetables, and protein supplements to ensure a balanced intake.
Choice C reason: Mashed potatoes and gravy are not suitable for a full liquid diet. Although mashed potatoes are soft, they are not liquid and can be difficult to digest for someone on a full liquid diet. The gravy may also contain small particles or thickeners that are not appropriate for this diet. A full liquid diet is intended to include only foods that are completely liquid or will turn to liquid at room temperature.
Choice D reason: Chicken broth is an excellent choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without adding any solid particles to the diet. Chicken broth is gentle on the digestive system and can help maintain electrolyte balance.
Correct Answer is B
Explanation
Choice A Reason:
Ask close-ended questions is incorrect. Close-ended questions typically elicit short, specific responses such as “yes” or “no.” While they can be useful in certain situations, they do not provide enough information to thoroughly assess a client’s mental status. Open-ended questions allow the client to express themselves more fully, providing the nurse with better insight into their cognitive function.
Choice B Reason:
Ask open-ended questions is correct. Open-ended questions encourage the client to elaborate on their thoughts and feelings, which can reveal more about their mental status. This type of questioning helps the nurse assess the client’s orientation, memory, and thought processes more effectively.
Choice C Reason:
Use directive questions is incorrect. Directive questions are more structured and guide the client towards specific answers. While they can be useful for obtaining specific information, they do not allow for a comprehensive assessment of the client’s mental status.
Choice D Reason:
Use reflective questions is incorrect. Reflective questions are used to encourage the client to think more deeply about their responses and feelings. While they can be helpful in therapeutic settings, they are not the most effective for an initial assessment of mental status.
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