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. This statement is confrontational and asks why, which can escalate agitation rather than calm the patient.
B. This response is clear, firm, and sets limits on unsafe behavior while offering support. It reassures the patient that the nurse will maintain safety, but in a therapeutic, non-punitive way.
C. This is judgmental and blaming, which is not therapeutic and may increase hostility.
D. Threatening seclusion immediately without first trying therapeutic limit-setting escalates fear and aggression. Seclusion is a last resort after other interventions fail.
Correct Answer is B
Explanation
A. A dimly lit room can increase misperceptions and hallucinations, worsening fear.
B. The client is experiencing alcohol withdrawal delirium with hallucinations, agitation, and high risk for injury. Continuous monitoring ensures safety and allows immediate intervention.
C. Hydration is important, but it is not the priority compared to preventing injury during hallucinations.
D. Intermittent checks are not enough; the client requires continuous supervision for safety.
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