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 ["B","D","E"]

Explanation

Choice A reason: Instructing another nurse to record risks errors; the receiving nurse must document directly for accuracy. Scientifically, this violates chain-of-command and transcription protocols, as firsthand recording ensures fidelity to the provider’s intent, reducing miscommunication in medication orders.

Choice B reason: Asking for spelling clarifies the medication, preventing errors like sound-alikes (e.g., Celexa vs. Celebrex). Scientifically, this aligns with safety standards, as precise identification ensures correct drug administration, critical in telephone orders where auditory mistakes are common.

Choice C reason: Withholding until signed delays care; telephone orders allow immediate action with later signature (e.g., 24-48 hours). Scientifically, this contradicts urgent care needs, as timely treatment outweighs procedural lag, provided documentation and verification are complete.

Choice D reason: Recording date and time establishes a legal timeline, ensuring accountability and sequence of care. Scientifically, this is mandatory in telephone orders, supporting traceability and adherence to protocols, critical for auditing and patient safety in medication administration.

Choice E reason: Read-back confirmation verifies accuracy, reducing errors in verbal orders. Scientifically, this is evidence-based, as it ensures the provider’s intent matches the nurse’s record, safeguarding against misheard doses or drugs, a key step in safe prescribing practices.

A. Educate the infant's guardians about exchange transfusion. B. Administer granulocyte colony-stimulating factor. C. Initiate droplet precautions. D. Monitor the infant's lymphocyte count.

Correct Answer is D

Explanation

Choice A reason: Exchange transfusion treats severe conditions like hyperbilirubinemia, not HIV. It’s irrelevant for a 10-month-old’s ongoing viral management needs.

Choice B reason: Granulocyte colony-stimulating factor boosts neutrophils, not lymphocytes, in neutropenia. HIV targets CD4 cells, making this an ineffective intervention here.

Choice C reason: Droplet precautions suit respiratory infections, not HIV, which spreads via blood/body fluids. Standard precautions suffice, so this isn’t needed.

Choice D reason: Monitoring lymphocyte (CD4) count tracks HIV progression in infants. It guides antiretroviral therapy, a critical ongoing management step at 10 months.

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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 receiving a telephone prescription from a client’s provider. Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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