Review Practice Exercise 1

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Practice Exercise 1

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Total Questions : 4

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Question 1:

A client is experiencing acute confusion due to poisoning from an accidental exposure to toxic chemicals in the workplace. What type of behavior should the nurse expect this client to demonstrate upon admission to the nursing unit?

A. Inability to eat without experiencing nausea. B. Frequently verbalizing ambivalent feelings. C. Difficulty expressing ideas and needs. D. Despondency in the presence of family members.

Answer and Explanation

Choice A:

Nausea may occur with chemical exposure but is a gastrointestinal symptom, not the defining feature of acute confusion. The stem emphasizes cognitive impairment, making this option less appropriate.

Choice B:

Ambivalent feelings reflect emotional conflict but are not typical of acute delirium. The primary issue is disorganized thought and impaired communication, not frequent verbalization of mixed emotions.

Choice C:

Toxic poisoning alters cognitive processing and language function, resulting in difficulty expressing ideas and needs. This is consistent with acute delirium, where impaired attention and disorganized thinking are hallmark features. The nurse should expect communication deficits upon admission.

Choice D:

Despondency in the presence of family suggests depression or withdrawal. Acute confusion from poisoning presents with fluctuating cognition and communication deficits, not sustained despondency.

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Question 2:

A nursing student is studying delirium. Which of the following student statements indicates that learning has occurred? Select all that apply.

A. “The symptoms of delirium develop over a short time.” B. “Delirium permanently affects the ability to learn new information.” C. “Symptoms of delirium include the development of aphasia, apraxia, and agnosia.” D. “Delirium is a disturbance of consciousness.” E. “Delirium is always secondary to another condition.”

Answer and Explanation

Choice A:

Delirium symptoms develop rapidly over a short period (hours to days), contrasting with chronic cognitive disorders. This rapid onset is a hallmark distinguishing delirium from dementia and other slow-progressing cognitive impairments.

Choice B:

Delirium does not permanently impair new learning in the way chronic dementias do; it is typically reversible once the underlying cause is treated, and cognitive function often returns toward baseline.

Choice C:

Aphasia, apraxia, and agnosia are more characteristic of dementia and focal neurological deficits, not core features of delirium, which primarily involves fluctuating attention and consciousness rather than specific language or motor planning losses.

Choice D:

Delirium fundamentally involves a disturbance of consciousness, with reduced clarity of awareness and impaired focus, shifting attention and responsiveness. This altered state is central to its diagnostic criteria and differentiates it from other neurocognitive conditions.

Choice E:

Delirium is secondary to another condition, such as infection, metabolic imbalance, or substance withdrawal. It rarely presents as a primary disorder; instead, it reflects an acute physiological or toxic trigger affecting brain function.

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Question 3:

A nurse is caring for an 80-year-old postoperative patient who suddenly becomes confused, disoriented to time and place, and shows fluctuating attention. Which features indicate that the patient is experiencing delirium rather than chronic cognitive impairment? Select all that apply.

A. Acute onset over hours to days. B. Fluctuating course with worse symptoms at night. C. Persistent memory loss over months. D. Marked inattention and distractibility. E. Reversible if underlying cause is treated.

Answer and Explanation

Choice A:

Because the hallmark of delirium is a waxing and waning course, the nurse must perform continuous, serial assessments of the patient's mental status. Subtle changes in the ability to sustain attention or follow simple commands are often the earliest clinical indicators of an acute physiological decline, even before overt agitation or vital sign changes occur.

Choice B:

The immediate administration of antipsychotic medications before a thorough diagnostic assessment is contraindicated as these drugs can mask clinical symptoms and hinder the identification of the underlying cause. Pharmacological interventions are reserved for patients in severe distress or those posing an immediate safety risk after non-pharmacological strategies have failed.

Choice C:

Relying exclusively on neuroimaging results is inappropriate because delirium is a functional, rather than a primarily structural, brain disturbance. While CT or MRI scans may be used to rule out a stroke or intracranial hemorrhage, the diagnosis of delirium is fundamentally a clinical one based on history, bedside assessment, and the identification of precipitating medical factors.

Choice D:

Delaying clinical documentation until a formal diagnosis is confirmed is a violation of nursing standards and jeopardizes patient safety. Accurate, real-time charting of behavioral fluctuations and cognitive deficits is essential for the interdisciplinary team to recognize the fluctuating pattern that is diagnostic of delirium and to track the effectiveness of interventions.

Choice E:

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Question 4:

A client in the ICU exhibits visual hallucinations, restlessness, and sleep-wake reversal. Which nursing interventions are appropriate to manage the client’s delirium? Select all that apply.

A. Reorient the client frequently to person, place, and time. B. Maintain a well-lit, quiet, familiar environment. C. Administer high doses of sedatives routinely. D. Remove hazardous objects and ensure safety. E. Encourage use of glasses and hearing aids.

Answer and Explanation

Choice A:

Providing frequent reorientation is essential because delirium disrupts the client’s ability to process and retain information. Repetitive verbal cues regarding the current date, location, and identity help stabilize the client’s cognitive framework and reduce the anxiety associated with acute confusion.

Choice B:

Maintaining a well-lit environment during the day and a quiet atmosphere at night promotes circadian rhythm alignment. Reducing excessive noise and providing familiar items helps minimize sensory perceptual distortions and prevents the worsening of restlessness and agitation.

Choice C:

Routine administration of high-dose sedatives is contraindicated as it can worsen the underlying encephalopathy and prolong the duration of delirium. Benzodiazepines, in particular, often trigger paradoxical agitation and increase the risk of respiratory depression and further cognitive clouding in critically ill patients.

Choice D:

Ensuring client safety is a priority since restless and hallucinating clients are at high risk for falls or self-injury. Removing hazardous objects and providing continuous supervision prevents accidental trauma or the dislodgement of critical medical equipment like intravenous lines.

Choice E:

Encouraging the use of sensory aids reduces misinterpretation of environmental stimuli, which often triggers hallucinations. Correcting sensory deficits with glasses and hearing aids allows the client to perceive their surroundings accurately, thereby decreasing cognitive load and paranoia.

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Total Questions : 4

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Practice Exercise 1

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