A nurse is reinforcing teaching about delirium with the caregiver of a client. Which of the following information should the nurse include?
individuals who have this disorder have a flat affect."
This disorder is characterized by a sudden onset of mental confusion
individuals who have this disorder speak at a slow pace."
This disorder is not reversible."
The Correct Answer is B
A) "Individuals who have this disorder have a flat affect.": A flat affect, which refers to a lack of emotional expression, is more characteristic of conditions like depression or schizophrenia rather than delirium. Delirium typically involves fluctuating levels of consciousness, confusion, and altered attention, but a flat affect is not a defining feature.
B) "This disorder is characterized by a sudden onset of mental confusion.": This statement is correct. Delirium is characterized by a rapid onset of symptoms, including confusion, disorientation, and changes in cognition. The acute nature of delirium distinguishes it from other conditions like dementia, which develops gradually over time.
C) "Individuals who have this disorder speak at a slow pace.": While some individuals with delirium may speak slowly due to confusion or disorientation, this is not a defining characteristic of the disorder. Delirium can cause a variety of speech patterns, including rambling, incoherence, or even rapid speech depending on the individual’s cognitive state.
D) "This disorder is not reversible.": This statement is incorrect. Delirium is typically reversible if the underlying cause (such as infection, dehydration, or medication side effects) is identified and treated. Unlike progressive disorders like dementia, delirium can often be resolved with appropriate medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "A child who has leukemia and an absolute neutrophil count of 200/mm³ (2,500 to 8,000/mm³)."
This child is at significant risk for infection due to a severely low neutrophil count, indicating severe neutropenia. Discharge planning for this child would be inappropriate at this time since they need intensive monitoring and care to manage their immunocompromised status and prevent infections.
B) "A child who has a new diagnosis of type 1 diabetes mellitus and is receiving IV insulin."
This child is appropriate for discharge planning. A new diagnosis of type 1 diabetes requires thorough teaching for the family and child about blood glucose monitoring, insulin administration, dietary adjustments, and emergency management. While the child is receiving IV insulin in the hospital, once stabilized, they can be discharged with proper education and support to manage their condition at home.
C) "An adolescent who has cystic fibrosis and is receiving their yearly tune-up."
A cystic fibrosis "tune-up" refers to a period of treatment, often including IV antibiotics and respiratory therapy, to help manage the chronic condition. Since this is part of ongoing care and not an acute issue, discharge planning is not immediately appropriate until the "tune-up" is complete, and the adolescent has stabilized.
D) "An infant who has respiratory syncytial virus (RSV) and a respiratory rate of 70/min."
This infant is at risk for respiratory distress and requires close monitoring. A respiratory rate of 70/min in an infant is elevated, and the child may need additional respiratory support. Discharge planning should not be initiated until the infant's condition improves and they are stable enough to handle care at home.
Correct Answer is D
Explanation
A) I have occasional vaginal spotting: Vaginal spotting can occur as a side effect of medroxyprogesterone, especially in the first few months of use. While this should be monitored, it is not an immediate concern that requires urgent reporting unless the spotting becomes heavy or persistent, which could indicate other issues.
B) I have developed brown patches on my face: The development of brown patches on the face (known as melasma) is a known side effect of hormonal contraceptives, including medroxyprogesterone. Although this is an undesirable cosmetic effect, it is not an urgent medical concern that requires immediate attention.
C) I have breast tenderness: Breast tenderness is a common side effect of medroxyprogesterone and other hormonal medications. It is usually mild and resolves over time. While the client should continue to monitor the tenderness, it does not present an immediate risk or require urgent intervention.
D) I have intermittent calf pain: Intermittent calf pain could be a sign of a more serious complication, such as a deep vein thrombosis (DVT), especially since medroxyprogesterone can increase the risk of blood clots. This symptom should be reported immediately to the healthcare provider, as a DVT could potentially lead to a pulmonary embolism if left untreated, which is a life-threatening condition. Therefore, this is the priority finding to report.
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