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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? .

A.

Consistent state of depression

B.

Fluctuating level of orientation.

C.

Demonstrates obsessive behaviors.

D.

Family report of gradual memory loss.

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

Choice A rationale:

While pacing can indicate anxiety, this client is not currently a threat to themselves or others.

Choice B rationale:

This client is exhibiting aggressive behavior and could potentially harm themselves or damage property.

Choice C rationale:

Although this client’s behavior is disruptive, it is not immediately dangerous.

Choice D rationale:

This client’s repeated requests indicate anxiety, but they are not in immediate danger.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential Provider Prescription Expected or Unexpected? Explanation
Administer acyclovir. Unexpected Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause.
Administer lorazepam. Expected Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention.
Initiate 1:1 supervision. Expected The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion. Expected The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration.

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