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 D
Explanation
Choice A rationale:
Teaching sessions right before bedtime may not be effective as older adults may be tired and less able to concentrate.
Choice B rationale:
Establishing long-term goals can be overwhelming for older adults. Short-term goals are more manageable and achievable.
Choice C rationale:
Long teaching sessions may lead to fatigue and decreased concentration. Short, frequent sessions are more effective.
Choice D rationale:
Using “I” statements rather than “you” statements can help create a more positive and collaborative learning environment.
Correct Answer is D
Explanation
Choice A rationale:
This statement is generalizing the client’s feelings, which can lead to a lack of individualized care.
Choice B rationale:
This statement is not acknowledging the client’s feelings of grief, which can lead to a lack of trust in the nurse-client relationship.
Choice C rationale:
This statement is self-disclosing personal information, which can lead to boundary violations in the nurse-client relationship.
Choice D rationale:
This statement is encouraging the client to express their feelings, which can help in the grieving process.
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