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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 D

Explanation

A. Chronic deterioration refers to a gradual, long-term decline in functioning, not the sudden emergence of new or worsening psychotic symptoms.

B. While relapse can sometimes be related to nonadherence, there is no direct evidence here that the patient has stopped taking medication, so this cannot be assumed.

C. Psychoeducation may be helpful, but the immediate concern is the reemergence of psychotic symptoms, not just a lack of understanding about the illness.

D. The patient is displaying insomnia, tension, difficulty concentrating, and paranoid delusions, which are early warning signs of a psychotic relapse in schizophrenia. Prompt intervention is necessary to prevent full exacerbation.

A. Silence can provide meaningful moments for reflection. B. Patients withdraw if silences are prolonged. C. Silence helps patients know that what they said was understood. D. A nurse is responsible for breaking silences.

Correct Answer is A

Explanation

A. Using silence allows the patient time to process thoughts and feelings, encourages introspection, and can facilitate deeper communication during interviews.

B. While prolonged silence can sometimes make patients uncomfortable, its intentional and therapeutic use is beneficial when appropriately timed.

C. Reflecting or paraphrasing communicates understanding; silence alone does not confirm comprehension.

D. In therapeutic communication, the nurse does not have to immediately fill silence; allowing moments of quiet can be purposeful.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?

Correct Answer is A

Explanation

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