A nurse is reviewing assessment data collected from a post-operative patient. What assessment findings would serve as cues that the client may be experiencing hypoactive delirium? Select all that apply.
Slowed psychomotor activity
Impaired attention and concentration
Hallucinations and delusions
Decreased alertness or responsiveness
Agitation and restlessness
Correct Answer : A,B,D
Choice A Reason:
Slowed psychomotor activity.
Slowed psychomotor activity is a hallmark of hypoactive delirium. Patients with this type of delirium often exhibit reduced physical movement and slower reaction times. This symptom can make hypoactive delirium more challenging to recognize compared to the more obvious agitation seen in hyperactive delirium.
Choice B Reason:
Impaired attention and concentration.
Impaired attention and concentration are common in all forms of delirium, including hypoactive delirium. Patients may have difficulty focusing, sustaining, or shifting attention, which can significantly impact their ability to engage in daily activities or follow conversations.
Choice C Reason:
Hallucinations and delusions.
While hallucinations and delusions can occur in delirium, they are more commonly associated with hyperactive delirium. Hypoactive delirium is characterized more by withdrawal and decreased responsiveness rather than the presence of hallucinations or delusions.
Choice D Reason:
Decreased alertness or responsiveness.
Decreased alertness or responsiveness is a key feature of hypoactive delirium. Patients may appear drowsy, lethargic, or less responsive to their environment. This can sometimes be mistaken for depression or fatigue, making it crucial to differentiate hypoactive delirium from other conditions.
Choice E Reason:
Agitation and restlessness.
Agitation and restlessness are characteristic of hyperactive delirium, not hypoactive delirium5. In hypoactive delirium, patients are more likely to be withdrawn and less responsive rather than agitated or restless.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Assist the client to identify triggers or sources of stress.
This is the correct response. Before educating clients about relaxation techniques, it is essential to help them identify their specific triggers or sources of stress. Understanding what causes their stress allows for more tailored and effective relaxation strategies. This step ensures that the relaxation techniques taught are relevant and can directly address the client’s needs, leading to better outcomes in managing anxiety and stress.
Choice B Reason:
Educate the client’s family so they can be active participants in the therapy.
While involving the client’s family in therapy can be beneficial, it is not the primary action to take before educating the client about relaxation techniques. Family education can support the client’s overall treatment plan, but the initial focus should be on understanding the client’s individual stressors and needs.
Choice C Reason:
Perform a physical assessment to ensure the client is able to participate in this therapy.
Performing a physical assessment is important to ensure the client can safely participate in relaxation techniques. However, this step is secondary to identifying the client’s stress triggers. Once the triggers are identified, the nurse can then assess the client’s physical ability to engage in specific relaxation exercises.
Choice D Reason:
Obtain an order from the psychiatrist during the treatment team.
Obtaining an order from the psychiatrist may be necessary for certain interventions, but it is not typically required for teaching relaxation techniques. The nurse can independently educate clients on these techniques as part of standard nursing care for managing stress and anxiety.
Correct Answer is B
Explanation
Choice A Reason:
Clonazepam is to be used for long-term therapy in conjunction with buspirone.
This statement is incorrect. Clonazepam, a benzodiazepine, is typically used for short-term relief of anxiety symptoms due to its potential for dependence and tolerance1. Long-term use of benzodiazepines is generally avoided in favor of medications like buspirone, which do not carry the same risks of dependence.
Choice B Reason:
Clonazepam is to be used short-term until the buspirone takes full effect.
This is the correct response. Buspirone takes several weeks to achieve its full therapeutic effect. During this period, clonazepam may be used to manage acute anxiety symptoms. Once buspirone reaches its full effect, clonazepam can be tapered off to avoid long-term use and potential dependence.
Choice C Reason:
Buspirone should be taken as needed until clonazepam takes full effect.
This statement is incorrect. Buspirone is not intended for as-needed use; it must be taken consistently to maintain stable blood levels and achieve its therapeutic effect. Clonazepam, on the other hand, is used for short-term relief and should not be relied upon for long-term management of anxiety.
Choice D Reason:
Tolerance could result with long-term use of buspirone.
This statement is incorrect. Unlike benzodiazepines, buspirone does not typically cause tolerance or dependence with long-term use. It is considered a safer option for chronic management of anxiety disorders.
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