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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Preschoolers (ages 3-5) often exhibit magical thinking, believing their actions cause events like death. This egocentric view links bad behavior to parental loss as punishment, reflecting their developmental stage where causality is self-focused, not abstract, aligning with typical grief responses in this age group scientifically.

Choice B reason: Understanding universal mortality requires abstract thinking, which develops later (around adolescence). Preschoolers lack this cognitive capacity, focusing instead on concrete, self-related explanations. This advanced comprehension is inconsistent with their developmental stage, making it an unlikely response to parental death in this age group.

Choice C reason: Recognizing permanent loss (never waking up) emerges around school age (6-12), not preschool. Younger children see death as reversible, like sleep, due to limited abstract reasoning. This understanding exceeds their developmental grasp, misaligning with typical preschool grief perceptions rooted in concrete thinking.

Choice D reason: Curiosity about funerals may occur, but it’s not a defining preschool grief trait. Their focus is more on magical thinking or separation anxiety, not procedural interest. This response, while possible, lacks the developmental specificity of self-blame, making it less consistent with scientific age-related grief patterns.

A. Release the client’s restraints every 4 hr. B. Check the client’s status every hour. C. Obtain written consent by the client for the placement of the restraints. D. Document the client’s behavior leading to the initiation of the restraints.

Correct Answer is D

Explanation

Choice A reason: Releasing restraints every 4 hours lacks context; policy requires 2-hour checks with release if safe. Scientifically, this risks neglect, as frequent assessment ensures circulation and safety, making it less precise than behavior documentation.

Choice B reason: Hourly checks are good but not the action specified; 15-minute intervals are standard for restraints. Scientifically, this underestimates risk monitoring needs, as behavior justification is a legal and clinical priority over timing alone.

Choice C reason: Client consent isn’t required for restraints in emergencies; provider orders suffice. Scientifically, imminent harm overrides autonomy, and consent isn’t feasible mid-crisis, making this impractical and misaligned with restraint protocols.

Choice D reason: Documenting behavior justifies restraints, ensuring legal and ethical use for safety. Scientifically, this aligns with standards, as specific actions (e.g., aggression) validate intervention, providing a clinical basis critical for care continuity and review.

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A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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