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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A"}
Explanation
A. Neologisms are new words or expressions created by the individual, often with personal meaning only they understand. "Frobitz" is an example of a neologism.
B. Loose associations involve a lack of logical connection between thoughts and ideas, leading to disjointed or incoherent speech.
C. Delusional thinking involves holding false beliefs that are resistant to reason or contradictory to evidence.
D. Circumstantial speech involves excessive and unnecessary detail before getting to the point of a conversation.
Correct Answer is C
Explanation
A. The Michigan Alcohol Screening Test (MAST) is a tool used to screen for alcohol abuse or dependence, but it does not specifically assess withdrawal symptoms.
B. The CAGE questionnaire is used to screen for alcohol abuse, but it does not assess withdrawal symptoms.
C. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool used to assess the severity of alcohol withdrawal symptoms. It includes various criteria such as agitation, tremor, and hallucinations.
D. The Delirium Rating Scale (DMSE) is used to assess the severity of delirium, which can be caused by various factors including alcohol withdrawal, but it is not specific to alcohol withdrawal.
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