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 D

Explanation

A. Anhedonia is a symptom commonly associated with depression, characterized by a decreased ability to experience pleasure or interest in activities.

B. Aphasia is a language disorder that affects the ability to communicate. It may involve difficulty in speaking, understanding language, reading, or writing. This is not demonstrated in the scenario.

C. Akathisia is a side effect of some antipsychotic medications characterized by a feeling of inner restlessness and the need to move constantly. It is not demonstrated in the scenario.

D. Agnosia is a symptom of dementia characterized by the inability to recognize familiar objects, people, or places, despite the senses being intact. In this scenario, the client's inability to recognize that their glasses are not a form of identification indicates agnosia.

A. Flat affect and hygiene needs B. Social isolation and anhedonia C. Hallucinations and delusions D. Withdrawal and avolition

Correct Answer is C

Explanation

A. Flat affect (lack of emotional expression) and hygiene needs are negative symptoms, not positive symptoms.
B. Social isolation and anhedonia (inability to experience pleasure) are also negative symptoms, not positive symptoms.
C. Positive symptoms involve the presence of abnormal experiences or behaviors that are not present in healthy individuals. Hallucinations (perceiving things that aren't there) and delusions (strongly held false beliefs) are examples of positive symptoms.
D. Withdrawal (lack of interest or participation in social activities) and avolition (lack of motivation) are negative symptoms, not positive symptoms.

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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

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