A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?

Demonstrates obsessive behaviors

Fluctuating level of orientation

Family report of gradual memory loss

Consistent state of depression

Answer and Explanation

The Correct Answer is B

A.   Obsessive behaviors, such as repetitive actions or fixations on specific thoughts or tasks, can be indicative of delirium. Delirium often manifests with altered behavior patterns that are unusual for the individual, including obsessive or compulsive-like behaviors that are not typical of their baseline mental status. However, this is not specific to delirium.
B.   Fluctuating orientation, where the client is sometimes alert and oriented and at other times confused or disoriented, is a hallmark of delirium. Unlike dementia, which typically presents with a more steady decline in cognitive function, delirium is characterized by rapid changes in mental status over hours to days. This fluctuation is important to note as it strongly suggests delirium rather than other chronic cognitive impairments.
C.   Gradual memory loss reported by family members is more suggestive of chronic conditions such as dementia rather than delirium. Delirium, in contrast, is characterized by acute onset and fluctuating course rather than a gradual decline in cognitive abilities over time.
D.   Depression can coexist with delirium, but a consistent state of depression without acute changes in mental status is less indicative of delirium. Delirium is characterized by rapid changes in cognition and behavior rather than a persistent mood disorder. Therefore, while depression should be assessed and managed appropriately, it is not typically a sign of delirium unless there are acute changes in mental status accompanying it.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B. When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C. Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D. Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

A. Encouraging thought-stopping to block undesirable thoughts B. Making a unit calendar to promote orientation C. Playing board games with other clients to enhance cognition D. Discussing childhood memories during group therapy

Correct Answer is D

Explanation

A. Thought-stopping is a cognitive behavioral technique used to interrupt and replace negative or distressing thoughts. However, it is not directly related to reminiscence therapy. Reminiscence therapy focuses on stimulating memories and promoting positive reflections on past experiences rather than blocking thoughts.
B. Creating a unit calendar can be a helpful strategy to promote orientation to time and events for older adults, especially those who may have memory impairments. While this is a valuable activity for maintaining orientation, it is not specifically reminiscence therapy. Reminiscence therapy involves recalling and discussing personal memories rather than focusing on current events.

C. Playing board games can indeed enhance cognition by stimulating various cognitive functions such as problem-solving, memory, and social interaction. However, it is not considered reminiscence therapy. Reminiscence therapy involves specific guided discussions or activities that evoke memories from the past, which can promote emotional well-being and socialization through shared experiences.
D. This is the most appropriate strategy for reminiscence therapy. Discussing childhood memories encourages older adults to recall and share past experiences, fostering a sense of identity, meaning, and connection. It can also enhance self-esteem and provide opportunities for social interaction within a therapeutic context.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement?

Correct Answer is D

Explanation

A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood." Which of the following responses should the nurse make?

A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care?

A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?

A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de- escalation techniques in the client's medical record?

A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations?

A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?