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 C
Explanation
Choice A rationale:
Excessive anxiety is not typically associated with antisocial personality disorder. It is more commonly seen in anxiety disorders.
Choice B rationale:
Withdrawn behaviors are more commonly associated with disorders such as depression or social anxiety disorder, not antisocial personality disorder.
Choice C rationale:
Exploiting others is a common characteristic of antisocial personality disorder. Individuals with this disorder often manipulate or deceive others for personal gain.
Choice D rationale:
Blunted affect, or reduced emotional expression, is not typically associated with antisocial personality disorder. It is more commonly seen in disorders such as schizophrenia.
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.
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