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. Seclusion is a last-resort intervention, not an initial step.
B. Staff meetings to ensure consistent approaches, structure, and limit-setting prevent staff fatigue, reduce defensiveness, and provide therapeutic consistency for the client.
C. Confronting the patient directly about unacceptable behavior may escalate agitation and is not the most effective prevention strategy.
D. Group discussions with patients about one individual’s behavior would be inappropriate and non-therapeutic.
Correct Answer is B
Explanation
A. This is an example of insight into underlying fear, not rationalization.
B. Rationalization involves providing a justifiable-sounding reason for unacceptable behavior (blaming the victim for provocation).
C. This reflects lack of awareness, not rationalization.
D. This shows acknowledgment of poor control, not an attempt to justify behavior.
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