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 A
Explanation
A. Labeling the bathroom door can provide a visual cue to help the older adult locate the bathroom, which may reduce episodes of incontinence.
B. Taking the older adult to the bathroom hourly is a good strategy, but it may not always be feasible or effective in preventing accidents.
C. Using disposable adult briefs may be necessary at times, but it should not be the first line intervention.
D. Limiting oral fluids to 1000 mL/day may lead to dehydration and is not an appropriate intervention for addressing incontinence.
Correct Answer is D
Explanation
A. Neologisms refer to made-up words or phrases that have meaning only to the individual. The client's response does not include invented terms but rather consists of real words that are nonsensically grouped.
B. Echolalia is the repetition of words or phrases spoken by others. The client's response does not reflect repetition of the nurse's words but rather a disjointed response of their own.
C. Pressured speech involves rapid and often incoherent speech that reflects a sense of urgency. The client's response lacks the rapid flow characteristic of pressured speech.
D. Clang association is characterized by speech in which the individual connects words based on their sound rather than their meaning. The client's response ("medications, abbreviations, deviations, mediations") demonstrates this pattern, as the words are linked by similar sounds rather than by content or coherent thought.
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