A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?

A decreased level of consciousness with intermittent periods of hypervigilance.

A slow onset of confusion and agitation.

A decrease in the client's output and vital signs.

The symptoms have lasted longer than a month.

Answer and Explanation

The Correct Answer is A

A.   Delirium is characterized by a fluctuating level of consciousness, which can include periods of hypervigilance.
B.   A slow onset of confusion and agitation is more characteristic of dementia rather than delirium.
C.   A decrease in output and vital signs may indicate a different condition, but it is not specific to delirium.
D.   Delirium is characterized by an acute onset and is typically short-lived, usually lasting days to weeks. Symptoms lasting longer than a month would suggest a different diagnosis.

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Correct Answer is A

Explanation

A. This outcome is specific, measurable, and timebound. It addresses the client's impaired social interactions and sets a realistic expectation for improvement within a short timeframe.
B. While this outcome is specific, it may not be achievable within a short timeframe and may not directly address the issue of egocentrism.
C. This outcome focuses on verbalization but may not necessarily lead to actual interaction or address the issue of egocentrism.
D. While this outcome is relevant, it is not as specific or timebound as option A.

A. "Attempts to communicate by using rhyming words." B. "Nonverbals indicate communication with unseen others." C. "Verbalizes happiness about trip to park which was not based in fact." D. "Rambles about early childhood experiences jumping from topic to topic."

Correct Answer is C

Explanation

Confabulation involves the fabrication of details or events to fill in gaps in memory. In this case, the client is expressing happiness about a trip to the park that did not actually occur, which is an example of confabulation.

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A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?

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Naxlex Comprehensive Predictor Exams

A client diagnosed with bipolar II disorder has a problem statement of impaired social interactions related to egocentrism. Which short-term correctly written outcome is an appropriate expectation for this client problem?

Correct Answer is A

Explanation

Which nursing documentation entry accurately describes a client's use of confabulation?

Correct Answer is C

Explanation

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