A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?
Echopraxia
Aphasia
Acute onset of confusion
Inability to read
The Correct Answer is C
Choice A reason: Echopraxia, mimicking movements, is linked to psychiatric conditions like schizophrenia, not delirium. Delirium features disordered cognition from physiological causes (e.g., infection), not motor imitation. Scientifically, this lacks relevance to delirium’s acute, fluctuating mental state driven by underlying medical issues.
Choice B reason: Aphasia, a language deficit, stems from brain damage (e.g., stroke), not delirium’s reversible cognitive disruption. Delirium affects attention and awareness, not specific linguistic skills. Scientifically, this is distinct from delirium’s diffuse, temporary confusion tied to systemic or metabolic disturbances.
Choice C reason: Acute onset of confusion defines delirium, a sudden cognitive decline from causes like infection or drugs. It’s reversible with treatment, featuring inattention and disorientation, aligning with scientific criteria as a hallmark symptom distinguishing it from chronic conditions like dementia.
Choice D reason: Inability to read relates to literacy or focal brain injury, not delirium. Delirium impairs global cognition—attention and memory—not specific skills like reading unless confusion interferes indirectly. Scientifically, this isn’t a core feature, as delirium’s impact is broader and transient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Evaluating restraint need requires nursing judgment, beyond assistive personnel scope. It involves assessing behavior and alternatives, reserved for licensed staff only.
Choice B reason: Circulation checks demand clinical assessment skills, like pulse and color evaluation. This exceeds assistive personnel training, requiring a nurse’s expertise instead.
Choice C reason: Educating family about restraints involves explaining medical rationale, a nursing role. Assistive personnel lack authority to provide such detailed clinical instruction.
Choice D reason: Assisting with range-of-motion exercises is within assistive personnel scope. It supports mobility under nurse direction, safely maintaining hand function in restraints.
Correct Answer is D
Explanation
Choice A reason: Persistent contractions signal labor or abruption, not previa. Placenta previa causes painless bleeding from placental positioning, not uterine activity.
Choice B reason: Increased fetal movement isn’t tied to previa; it’s a fetal response indicator. Previa’s hallmark is maternal bleeding, not fetal behavior changes.
Choice C reason: Rigid abdomen suggests abruption with clot formation, not previa. Previa bleeding is external, leaving the uterus soft, not tense.
Choice D reason: Bright red vaginal bleeding is classic in placenta previa, from low placental implantation. It’s painless, distinguishing it from other complications.
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