Which assessment finding would the nurse expect to see in a patient experiencing delirium? (Select all that apply)
Agnosia
Impaired level of consciousness
Disorientation to place, and time
Apathy
Wandering attention
Correct Answer : A,B,C,E
A. Delirium can cause difficulty recognizing objects, people, or places, which is a form of agnosia.
B. Patients with delirium often have fluctuating levels of consciousness, ranging from lethargy to hyperalertness.
C. Delirium commonly affects orientation, causing confusion about where they are or what time it is.
D. Apathy is more characteristic of depression or dementia rather than the acute, fluctuating attention seen in delirium.
E. Patients with delirium often display inattention and an inability to focus, leading to distractibility and wandering attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Distinguishing between reality and fantasy shows intact cognition, not mental illness.
B. A persistent sad, hopeless mood suggests depression, a hallmark of mental illness when symptoms are severe and ongoing.
C. Occasional anxiety and insomnia can be normal stress responses, not necessarily mental illness.
D. Difficulty making a decision about work is a common life stressor, not a clear sign of mental illness.
Correct Answer is B
Explanation
A. Offering platitudes can minimize the patient’s feelings and may shut down further disclosure.
B. Directly asking about suicidal thoughts is the most important and therapeutic response because the statement expresses hopelessness, a major risk factor for suicide. This question assesses immediate safety and guides next steps (ask about intent, plan, means; implement suicide precautions and notify the provider as indicated).
C. Exploring past interests can be therapeutic later, but it does not address the immediate safety concern suggested by the patient’s hopeless statement.
D. Saying you don’t understand is vague and avoids addressing the potential crisis; a direct, nonjudgmental assessment of suicidal ideation is required.
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