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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Discouraging visitation from the client’s family could increase feelings of isolation and confusion, which could exacerbate delirium.
Choice B rationale:
A high-stimulation environment could overstimulate the client and worsen delirium.
Choice C rationale:
Limiting the client’s need to make decisions can reduce stress and confusion, which can help manage delirium.
Choice D rationale:
Keeping the client’s room dark at night could disrupt the client’s sleep-wake cycle and potentially worsen delirium.
Correct Answer is ["The correct answers are choices: Approach client slowly"," \r\n Maintain a low stimulation environment"," \r\n and Reorient client to person"," \r\n place"," \r\n and time frequently. Approach client slowly rationale: This is a therapeutic intervention for clients who are confused and agitated. It can help to reduce anxiety and promote trust. Alternate nursing staff daily rationale: This is not recommended as it can lead to confusion and anxiety in the client. Consistency in care providers can help to promote trust and understanding. Maintain a low stimulation environment rationale: This can help to reduce agitation and confusion in the client. A calm and quiet environment can promote relaxation and understanding. Reorient client to person"," \r\n place"," \r\n and time frequently rationale: This is a therapeutic intervention for clients who are confused. It can help to promote reality orientation and reduce confusion. Provide the client with limited information about the diagnosis rationale: This is not recommended as it can lead to confusion and anxiety in the client. Clients have the right to be fully informed about their diagnosis and treatment."]
No explanation
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