A patient exhibits confusion, disorientation, and an inability to focus on a conversation. Which of the following would be the most likely assessment finding? (Select one, all, or some).
Obtunded
Coma
Stupor
Delirium
Mild lethargy
Correct Answer : D
A. Obtunded: Obtunded patients show decreased alertness and respond slowly to stimuli, often requiring repeated stimulation to maintain attention. This level of consciousness is more severe than confusion and typically involves reduced awareness.
B. Coma: Coma is a state of deep unconsciousness where the patient is unarousable and unresponsive to external stimuli. It is much more severe than confusion or disorientation and is unlikely in a patient who is still able to interact, even if confused.
C. Stupor: Stupor refers to a condition where the patient is mostly unresponsive and only responds to vigorous or painful stimuli. It is more severe than confusion and involves markedly diminished awareness.
D. Delirium: Delirium is characterized by acute onset of confusion, disorientation, impaired attention, and fluctuating levels of consciousness. It best matches the patient's symptoms of confusion, disorientation, and inability to focus.
E. Mild lethargy: Mild lethargy involves drowsiness and reduced energy but does not typically impair orientation or the ability to focus as severely as seen in this patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Urine output <30mL/hour: Oliguria is defined as a markedly reduced urine output, typically less than 400 mL per day or less than 30 mL per hour. It indicates decreased kidney function or perfusion and is common in progressive renal conditions.
B. Absence of urine output: This describes anuria, not oliguria. Anuria is defined as urine output less than 100 mL per day and signifies severe kidney failure or complete urinary tract obstruction.
C. Increased urine output: This describes polyuria, often associated with conditions like uncontrolled diabetes mellitus or diabetes insipidus, not oliguria.
D. Urine output >100mL/hour: This is well above the threshold for oliguria and may suggest diuresis or overhydration. It does not meet the criteria for decreased kidney output.
Correct Answer is D
Explanation
A. Low-residue diet predisposes to colon diverticula: A low-fiber (low-residue) diet leads to harder stools and increased intraluminal pressure during bowel movements, which promotes the formation of diverticula, especially in the sigmoid colon.
B. Diverticulum may become infected, causing diverticulitis: When fecal material becomes trapped in a diverticulum, it can lead to localized infection and inflammation known as diverticulitis, which may cause pain, fever, or even abscess formation.
C. Ulceration of lining of diverticula caused by fecal material in the diverticula may cause bleeding from the ulcerated diverticulum: Trapped fecal matter can irritate and ulcerate the mucosal lining of diverticula, leading to localized bleeding, which may be seen as rectal bleeding or blood in the stool.
D. Diverticula predispose to colon carcinoma: Diverticulosis is not considered a premalignant condition. Although both conditions may coexist in older adults, the presence of diverticula does not increase the risk of colon cancer.
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