A young man with malaria spikes a temperature of 105 F (40.5°C) and begins to hallucinate. How should the nurse assess this?
Anxiety disorder
Delirium
Early onset dementia
Psychotic break
The Correct Answer is B
A. While anxiety can cause symptoms like hallucinations, it's typically not associated with a sudden onset due to a physical illness and a high fever.
B. Delirium is an acute confusional state often caused by medical conditions, such as infections (like malaria), and is characterized by rapid onset, fluctuations in consciousness, and disturbances in attention, perception, and cognition. Hallucinations are a common symptom of delirium.
C. Dementia is a progressive decline in cognitive function, which usually develops gradually over time, not suddenly due to a fever.
D. While hallucinations are a symptom of psychosis, they are typically associated with underlying mental health conditions rather than a sudden physical illness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Preferring to eat meals while watching TV is a common behavior that is not specifically associated with suicidal ideation. It may simply reflect the adolescent's comfort or routine preferences rather than a sign of continued suicidal intent.
B. Giving away personal belongings, such as a CD collection, can be a sign that the adolescent is making arrangements for their belongings in case of death. This behavior can sometimes suggest that the individual may be planning for their end, which could indicate lingering suicidal thoughts. It's important to explore this behavior further with the adolescent to understand their intentions and state of mind.
C. While avoidance of discussing the suicide attempt may indicate emotional distress or a reluctance to engage, it does not directly point to ongoing suicidal intent. It could also reflect a desire for privacy or difficulty in expressing feelings, rather than a clear indication of suicidal ideation.
D. Adolescents often express a desire to spend more time with peers rather than family, which is a common developmental behavior. This preference alone does not necessarily indicate suicidal intent and is more reflective of typical adolescent social behavior.
Correct Answer is C
Explanation
A. While it might be helpful to reduce distractions, forcing someone to sit down can be counterproductive and stressful. It's important to respect the client's needs and preferences.
B. Changing key words might confuse the client further, as they may lose the context of the conversation. It's better to rephrase the sentence using simpler language.
C. This is the most effective communication technique for individuals with Alzheimer's disease. As the disease progresses, language skills deteriorate, and simple communication is easier to understand.
D. While hand gestures can be helpful in some cases, they should be used in conjunction with verbal communication, not as a replacement. Overreliance on gestures can be confusing for the client.
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