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.

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Correct Answer is A

Explanation

A. One of the nurse's responsibilities during the informed consent process is to witness the client signing the consent form. This ensures that the client voluntarily agrees to undergo ECT after receiving adequate information about the procedure, its risks, benefits, and alternatives. By witnessing the signature, the nurse confirms that the client's consent is documented appropriately and legally.
B. Nurses may provide general information about ECT and its alternatives, but the detailed discussion about treatment options and their implications usually occurs during the consultation with the provider.
C. Determining if a client is competent to give consent is a legal determination typically made by a healthcare provider or a legal representative, not the nurse.
D. It is not the nurse's role to discuss the specific benefits of ECT, as these discussions are the responsibility of the healthcare provider leading the client's care.

A. Excessively anxious B. Exploitive of others C. Withdrawn behaviors D. Blunted affect

Correct Answer is B

Explanation

A. This is not typically associated with antisocial personality disorder. People with ASPD often exhibit a lack of remorse and guilt, and they may be prone to impulsive and risk-taking behaviors rather than excessive anxiety.
B. Exploitation of others is a hallmark feature of antisocial personality disorder. Individuals with ASPD may manipulate, exploit, or deceive others for personal gain without regard for others' feelings or rights.
C. Withdrawn behaviors, where individuals tend to isolate themselves or avoid social interactions, are not characteristic of antisocial personality disorder. In fact, individuals with ASPD tend to be socially charming and may seek out social situations to manipulate or exploit others.
D. Blunted affect refers to a reduced emotional expression, which is not typically a prominent feature of antisocial personality disorder. Individuals with ASPD may exhibit superficial charm and can be engaging, although they may lack empathy or genuine emotional responsiveness.

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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 assisting in the care of a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following is the nurse's role during the informed consent process?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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