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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Wernicke encephalopathy is caused by thiamine (Vitamin B1) deficiency, but it is not characterized by thiamine deficiency itself.
B. Wernicke encephalopathy is characterized by lesions in the hypothalamus and mammillary bodies in the brain.
C. While cognitive impairment may be present, this is not the primary characteristic of Wernicke encephalopathy.
D. Double vision and rapid eye movement are symptoms of Wernicke encephalopathy, but they are not the irreversible complication itself.

A. The client displays agitation. B. The client becomes suddenly cheerful. C. The client experiences psychomotor retardation. D. The client does not attend group therapy.

Correct Answer is B

Explanation

A. Agitation can be a sign of distress, but sudden cheerfulness may be indicative of a decision to act on suicidal thoughts, as the individual may feel relieved to have made a decision.
B. Sudden cheerfulness can be a concerning sign, as it may indicate that the client has made a decision to carry out suicidal thoughts.
C. Psychomotor retardation is a symptom of depression and may not necessarily indicate imminent risk of suicide.
D. Not attending group therapy may be a sign of withdrawal or isolation, but it does not directly indicate immediate suicidal risk.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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