An older adult client has been admitted due to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive impairment?

The client has a family history of cognitive disorders.

The client has recently begun a new medication.

The client's cognition has declined over a period of several months to a year.

The client has a history of hypertension.

Answer and Explanation

The Correct Answer is B

Choice A reason: Family history suggests dementia, not delirium. Dementia progresses slowly, unlike delirium’s acute onset, making this less indicative of the sudden cognitive shift typical of delirium, especially without a rapid trigger in this case fully here.
Choice B reason: New medication often causes delirium in older adults via anticholinergic effects or toxicity. This acute, reversible change aligns with delirium’s hallmark sudden onset, making it the most suggestive finding for this cognitive impairment accurately here.
Choice C reason: Decline over months to a year fits dementia, not delirium. Delirium is acute, not chronic, excluding this gradual progression as a sign of the rapid cognitive shift delirium presents in this assessment entirely and fully.
Choice D reason: Hypertension risks vascular dementia, not delirium. It’s a chronic factor, not an acute trigger, missing delirium’s sudden, reversible nature tied to immediate causes like drugs, rendering it less relevant here comprehensively and clearly.

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Correct Answer is C

Explanation

Choice A reason: Visible jugular pulse supine is normal, as gravity pools venous blood. However, the question seeks upright findings. This is expected lying down, not sitting, misaligning with the healthy standard for an upright position in this context fully.

Choice B reason: Distended jugular veins at 45 degrees suggest elevated central venous pressure, like in heart failure, not health. In a healthy client, veins collapse at this angle, making this an abnormal, not expected, finding for jugular assessment here.

Choice C reason: No visible jugular pulse upright is normal in health, as venous pressure drops below the clavicle when sitting. This reflects proper heart function and gravity’s effect, aligning with expected findings in a healthy client’s neck vessel exam accurately.

Choice D reason: Full jugular distension in high Fowler’s (60-90 degrees) indicates pathology, like right heart failure, not health. Healthy veins collapse at this elevation, making this an abnormal finding, not the expected norm for jugular assessment entirely here.

A. Acute otitis media B. Serous otitis media C. Scarring from previous infections D. Intact tympanic membrane

Correct Answer is D

Explanation

Choice A reason: Acute otitis media shows a red, bulging tympanic membrane due to bacterial infection and pus. A pearly gray, shiny appearance contrasts this, indicating no acute inflammation or fluid, ruling out this active middle ear condition entirely.

Choice B reason: Serous otitis media presents with amber fluid behind a retracted or neutral tympanic membrane, not pearly gray and shiny. This suggests no sterile effusion, distinguishing it from the normal, healthy membrane observed in this inspection clearly.

Choice C reason: Scarring from past infections appears as white, opaque patches on the tympanic membrane, not uniform pearly gray shininess. This finding lacks the irregular, thickened look of scar tissue, pointing to an unscathed membrane instead here.

Choice D reason: A pearly gray, shiny tympanic membrane is normal, reflecting light off an intact, healthy eardrum. This lacks signs of infection or fluid, aligning with standard anatomy where the membrane’s cone of light confirms its integrity fully.

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An older adult client has been admitted due to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive impairment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be expected in a healthy client?

Correct Answer is C

Explanation

While inspecting the tympanic membrane the nurse notes a pearly gray and shiny appearance. What would this finding indicate?

Correct Answer is D

Explanation

The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

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The nurse is assessing cranial nerves 3, 4 and 6 (oculomotor, trochlear and abducens). Which technique might the nurse use to assess all three in one technique?

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