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:
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.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
Diarrhea is not typically associated with anorexia nervosa. Constipation is more common due to reduced food intake.
Choice B rationale:
Hypotension can occur in anorexia nervosa due to decreased circulating blood volume from inadequate fluid and food intake.
Choice C rationale:
Cold extremities can be a sign of anorexia nervosa due to the body’s attempt to conserve heat in response to inadequate caloric intake.
Choice D rationale:
Tooth erosion can occur in anorexia nervosa due to frequent vomiting, which exposes the teeth to stomach acid.
Choice E rationale:
Lanugo, or fine body hair, can develop in anorexia nervosa as the body’s attempt to insulate itself due to loss of body fat.
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