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 A

Explanation

Choice A reason: Turning the head against resistance assesses neck muscles, not the temporomandibular joint (TMJ), which hinges the jaw. TMJ evaluation requires jaw-specific movements, not cervical rotation, indicating a misunderstanding of TMJ anatomy and function, misaligning with headache assessment needs.

Choice B reason: Opening the mouth wide while fingers are placed near the ear directly tests TMJ range of motion and joint integrity. This is a standard technique to detect dysfunction or pain, correctly targeting the jaw’s articulation point relevant to headaches.

Choice C reason: Moving the jaw side to side evaluates TMJ lateral excursion, a key diagnostic motion. Pain reporting during this action helps identify joint issues tied to chronic headaches, making it an appropriate and precise instruction for TMJ assessment.

Choice D reason: Pushing out and pulling in the jaw tests TMJ protrusion and retraction, critical for assessing joint stability and sounds like popping, which may link to headache etiology. This instruction correctly focuses on TMJ mechanics and symptoms.

A. "It is important to have general hearing screening tests every year." B. "Ototoxic medications can damage hearing and should be avoided." C. "Wear hearing protectors when in loud environments." D. "Hearing loss can be caused by long or repeated sounds above 85 decibels."

Correct Answer is C

Explanation

Choice A reason: Annual hearing screenings detect loss, not prevent it. In manufacturing, where noise exposure is immediate, this reactive measure doesn’t address the primary risk of loud machinery damaging cochlear hair cells, missing proactive protection entirely.

Choice B reason: Avoiding ototoxic drugs like aminoglycosides prevents chemical hearing damage, but manufacturing noise is the dominant risk. This advice is secondary to physical noise control, less relevant to the plant’s environmental hazard than direct protective measures here.

Choice C reason: Hearing protectors, like earplugs, block noise above 85 decibels, preventing cochlear damage in loud manufacturing settings. This primary prevention targets the main risk—prolonged sound exposure—directly safeguarding workers’ auditory health effectively and immediately in context.

Choice D reason: Stating noise above 85 decibels causes loss educates but doesn’t prevent. It’s factual—hair cells die from overexposure—but lacks actionable protection for manufacturing workers facing this risk daily, making it less practical than wearing protectors.

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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

A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client's temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

Correct Answer is A

Explanation

A nurse is planning a personal safety educational session for those who work in a manufacturing plant. Which of the following would be an important risk prevention measure to include regarding hearing?

Correct Answer is C

Explanation

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