A nurse is collecting data from an older adult client who was admitted with heart failure.
The nurse should report which of the following findings to the provider as an indication of delirium? .
Consistent state of depression
Fluctuating level of orientation.
Demonstrates obsessive behaviors.
Family report of gradual memory loss.
The Correct Answer is B
Choice A rationale:
A consistent state of depression is not indicative of delirium, but rather a mood disorder.
Choice B rationale:
Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
Choice C rationale:
Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
Choice D rationale:
Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.
Choice B rationale:
Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.
Choice C rationale:
The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.
Choice D rationale:
Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.
Correct Answer is B
Explanation
Choice A rationale:
Attending a cognitive behavioral therapy class does not require informed consent as it is a non-invasive form of treatment.
Choice B rationale:
Informed consent is necessary when taking an experimental medication to ensure the client understands the potential risks and benefits.
Choice C rationale:
Light therapy is a non-invasive treatment and does not typically require informed consent.
Choice D rationale:
Participating in a group exercise program is a non-invasive form of treatment and does not require informed consent.
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