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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: This statement shows that the client is willing to ground their decisions in reality, which is a key step in managing paranoid personality disorder.

Choice B reason: Trusting others is important, but it does not indicate that the client has learned to validate their ideas before acting.

Choice C reason: Differentiating true suspicions is part of managing the disorder, but it does not demonstrate an understanding of the need to validate ideas with others.

Choice D reason: Understanding the origins of paranoid thinking is insightful, but it does not show that the client has learned to validate their ideas before taking action.

A. Check the client's pupil reactivity. B. Perform a developmental screening test. C. Prepare the client for a CT scan. D. Obtain a urine specimen. E. Monitor the client’s vital signs frequently.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is teaching a client with paranoid personality disorder to validate ideas with another person before taking action. Which statement made by the client indicates that the teaching is effective?

Correct Answer is B

Explanation

A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

In the inpatient behavioral health unit, which clients require someone to make decisions regarding their medical and psychiatric care in their best interest? Select all that apply.

A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

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 client and their spouse come to talk with the nurse about their suspicion that the client may have intermittent explosive disorder after researching it on the internet. Which behaviors reported by the spouse indicate that the client may be experiencing this disorder? (Select all that apply.)

A client has a history of excessive fear of water. Which term should the nurse use to describe this specific phobia, and under what subtype is this phobia identified?

Which statement(s) made by the spouse indicates that they are exhibiting enabling behaviors? Select all that apply.

A client diagnosed with Schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should the nurse expect a physician to order to address this type of symptom?