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. Administering diazepam may be part of the treatment plan for delirium tremens, but ensuring adequate hydration and addressing potential electrolyte imbalances is the first priority.
B. Raising the side rails is important for safety, but it is not the highest priority action at this time.
C. Obtaining a medical history is important for comprehensive care, but in this urgent situation, addressing fluid and electrolyte balance is the first priority.
D. Starting intravenous fluids is crucial for rehydration and addressing potential electrolyte imbalances, which is the priority in this emergency situation.

A. The client believes the message from the television is that he is "a burden to everyone." B. The client believes the President of The United States is his brother. C. The client believes the voice he hears is telling him to hurt someone. D. The client believes the Central Intelligence Agency (CIA) is hunting for him to destroy him.

Correct Answer is D

Explanation

A. This option describes a feeling of burden, but it doesn't specifically address persecution.
B. This option describes a delusion involving a familial relationship with a public figure, but it doesn't specifically address persecution.
C. This option describes a command hallucination, which can be related to violence, but it doesn't directly address feeling persecuted.
D. This option directly addresses the feeling of persecution by believing a powerful agency is actively seeking to harm the client.

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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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