An 80 year-old client, together with his daughter, arrived at the medical surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?
"Maybe it's just caused by aging. This usually happens at his age."
"The changes in his behavior came on so quickly! I wasn't sure what was happening."
"Dad just didn't seem to know what he was doing. He has been forgetful for years."
"Dad has always been so independent. He's lived alone for years since Mom died."
The Correct Answer is B
A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.
B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.
C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.
D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A schizophrenic episode Schizophrenic episodes are characterized by a complex interplay of symptoms including delusions, hallucinations, disorganized thinking, and altered perceptions. While the client is experiencing altered perceptions, the sudden onset and specific description are more indicative of hallucinogen ingestion.
B. Hallucinogen ingestion The client's description of altered perception, feeling outside of their own body, and visual distortions are indicative of hallucinogen ingestion. This class of substances can cause profound alterations in perception, leading to hallucinations and distorted sensory experiences. The slightly elevated vital signs may be a physiological response to the effects of the hallucinogen.
C. Opium intoxication Opium is an opioid and its effects are characterized by sedation, respiratory depression, and miosis (pupil constriction). The client's description of altered perception and feeling outside of their body are not typical of opium intoxication.
D. Cocaine overdose Cocaine is a stimulant and its effects are characterized by increased heart rate, blood pressure, and hyperarousal. The client's description of altered perception and feeling outside of their body are not typical of cocaine overdose.
Correct Answer is B
Explanation
A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.
B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.
C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.
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