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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This option is not appropriate for a client with acute delirium. Delirium is characterized by fluctuating levels of consciousness, attention, and cognition. High-stimulation environments, such as loud noises or bright lights, can exacerbate confusion and agitation in these clients. Therefore, providing a calm and quiet environment is crucial to help reduce symptoms of delirium.
B. Delirium can often be worsened during nighttime due to factors like disruption of sleep-wake cycles and disorientation in a new environment. Keeping the client's room dark at night helps to promote rest and reduce disturbances. However, this is not the most important intervention.
C. Family support and presence are typically beneficial for clients, even those with delirium. Family members can provide familiarity, comfort, and assistance in reorienting the client. Discouraging visitation would not be appropriate unless the family members are contributing to increased agitation or confusion. Instead, it's important to educate family members on how to interact with and support the client effectively.
D. Clients with delirium often experience impaired cognition, making decision-making challenging for them. Limiting the client's need to make decisions can help reduce their stress and frustration. It's important for the nurse to simplify choices when possible and provide guidance and support as needed. This approach can help alleviate cognitive load and improve the client's ability to cope.
Correct Answer is D
Explanation
A. Role-playing is a useful technique to teach and reinforce new behaviors by allowing the child to practice appropriate responses in simulated situations. While role-playing can be beneficial, it is not specifically related to redirection technique. Redirection involves diverting a child's attention or behavior away from inappropriate or disruptive actions towards more acceptable behaviors.
B. Moving closer to a child who is agitated can be a strategy to provide physical proximity and support, especially to prevent escalation of behavior or to intervene if necessary. However, it is not directly related to redirection technique.
C. Ignoring attention-seeking behaviors is a common behavior management strategy aimed at reducing reinforcement of undesirable behaviors. While ignoring can be effective in some situations, it is not specifically redirection technique.
D. This statement correctly reflects the redirection technique. Redirection involves redirecting the child's focus or behavior from negative or inappropriate actions towards positive and appropriate activities or tasks. By re-engaging the child in an appropriate activity, the parent can effectively redirect their attention and energy, potentially preventing or diffusing disruptive behaviors.
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