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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. This involves memory loss due to brain injury or alcohol abuse, not acute fluctuating confusion.

B. Alzheimer’s causes progressive, irreversible memory decline that develops gradually, not suddenly over 2 days.

C. Delirium is characterized by acute onset, fluctuating levels of orientation, confusion, speech changes, and impaired gait, often triggered by medications, infections, or metabolic issues.

D. Dementia develops slowly and progressively, not suddenly like delirium.

A. distorted thought self-control. B. sleep pattern stabilization, C. interest in the environment. D. developing an optimistic outlook.

Correct Answer is A

Explanation

A. Clients experiencing grandiose thinking during acute mania often have inflated self-esteem and unrealistic ideas of ability or importance, making controlling or monitoring their thoughts a priority nursing outcome.

B. While sleep disturbances are common in mania, this outcome does not directly address grandiose thinking.

C. Increased engagement in the environment may occur, but it is not the primary expected outcome for controlling grandiose thoughts.

D. Optimism may be present, but grandiosity involves exaggerated self-perceptions rather than realistic optimism.

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Which assessment finding would the nurse expect to see in a patient experiencing delirium? (Select all that apply)

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