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 C
Explanation
Choice A reason: Epigastric pain suggests GI issues, not TIAs. In hypertension, TIAs affect cerebral vessels, causing neurological deficits, not abdominal symptoms like this.
Choice B reason: Seizures stem from cortical irritation, not typical TIA vascular occlusion. Hypertension-related TIAs produce transient deficits, not convulsive activity usually.
Choice C reason: Sudden monocular vision loss (amaurosis fugax) is a classic TIA sign in hypertension. It reflects temporary retinal artery occlusion, resolving quickly.
Choice D reason: Left arm pain mimics cardiac issues, not TIAs. Hypertension TIAs target brain circulation, causing focal deficits, not referred pain patterns.
Correct Answer is C
Explanation
Choice A reason: Living wills can be updated anytime, not fixed. This misinformation contradicts legal flexibility, key for clients to understand in directives.
Choice B reason: Surrogates needn’t be family; any trusted person qualifies. Mandating family limits choice, misrepresenting the broad options in directive planning.
Choice C reason: A surrogate decides when the client can’t, per advance directives. This accurately informs about proxy roles, essential for incapacity planning.
Choice D reason: Attorneys aren’t required; forms suffice legally in most states. This overcomplicates surrogacy, deterring clients from completing directives unnecessarily.
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