The nurse is performing an assessment for a client brought in by a family member who states they think the client has dementia. When evaluating the assessment data, which finding indicates that the client may likely have delirium and not dementia?

The family member said the client started to forget people's names.

The confusion began suddenly after taking a newly prescribed antidepressant.

The client states they have been tired and sleeping a lot more than usual.

The family member states the client does not seem to enjoy previous activities.

Answer and Explanation

The Correct Answer is B

Choice A reason: Forgetting people's names can be a symptom of both dementia and delirium, but it is more commonly associated with the progressive cognitive decline seen in dementia.

Choice B reason: Sudden onset of confusion after starting a new medication, such as an antidepressant, is indicative of delirium, which can be triggered by drug interactions or side effects.

Choice C reason: Increased tiredness and sleep could be associated with either condition but are not specific indicators that would distinguish delirium from dementia.

Choice D reason: A loss of interest in previously enjoyed activities is a symptom that can be seen in dementia as part of a gradual decline in engagement and is not specific to delirium.

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Correct Answer is ["B","D"]

Explanation

Choice A reason: Having two nurses present at all times may not be necessary and could be overwhelming for the client, making them feel less in control.

Choice B reason: Continuous assessment of the client's anxiety level is important to ensure that the nurse can respond to the client's needs and maintain a sense of safety.

Choice C reason: While promoting independence is good, the client may need assistance, and providing it can be part of creating a safe environment.

Choice D reason: Asking for permission is crucial as it respects the client's autonomy and helps them feel in control of their body, which is essential for someone who has experienced abuse.

Choice E reason: Having security present outside the room may be excessive and could contribute to a feeling of being guarded or watched, which may not be conducive to feeling safe and secure.

A. Prepare for gastric lavage. B. Hold the medication and assess for early manifestations of toxicity. C. Check the client's medication record to assess whether the client has been refusing her lithium. D. Administer the morning dose of lithium.

Correct Answer is B

Explanation

Choice A reason: Gastric lavage is typically not the first-line treatment for lithium toxicity due to the risk of aspiration and potential complications. It is usually reserved for cases where the ingestion was recent and massive.

Choice B reason: When a client presents with an extremely elevated lithium level, it is crucial to hold further doses to prevent exacerbation of toxicity. The nurse should monitor for early signs of toxicity, which include gastrointestinal symptoms like nausea, vomiting, diarrhea, and neurological symptoms such as tremors, confusion, and ataxia. The normal therapeutic range for lithium is 0.6 to 1.2 mmol/L, and levels above 1.5 mmol/L are considered toxic.

Choice C reason: While it is important to review the medication record, the immediate concern with an extremely elevated lithium level is addressing the toxicity. Checking the medication record can be part of the assessment process but is not the priority action.

Choice D reason: Administering the morning dose of lithium could worsen the client's condition by increasing the lithium level further, which is already extremely elevated. This could lead to severe toxicity or even fatal consequences.

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The nurse is performing an assessment for a client brought in by a family member who states they think the client has dementia. When evaluating the assessment data, which finding indicates that the client may likely have delirium and not dementia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been a victim of abuse since childhood. Which actions by the nurse are important to ensure that the client feels safe, secure, and in control of their own body? Select all that apply.

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a client who has an extremely elevated lithium level. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A college student has been diagnosed with Generalized Anxiety Disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.)

A nurse is conducting a group session in the behavioral health unit for three clients on the topic of anxiety. The nurse determines that the session was successful based on which statement by the clients?

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.

A client with cognitive deficits is extremely suicidal and has not responded to antidepressants. The treatment team is considering electroconvulsive therapy (ECT). Which client information would impact the feasibility of this treatment option?

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?

A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply.)

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?