Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)
A. Agitation
Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.
B. Slow, flat speech
Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.
C. Visual hallucinations
Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.
D. Confusion
Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.
E. Rapid mood swings
Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.
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Full Explanation
Choice A rationale:
Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.
Choice B rationale:
Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.
Choice C rationale:
Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.
Choice D rationale:
Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.
Choice E rationale:
Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.
Similar Questions
A nurse is facilitating a group session for clients who have posttraumatic stress disorder.
Which of the following client statements indicates progression toward positive outcomes?
A. "I feel guilty that my fellow soldiers died in combat and I survived."
Expressing feelings of guilt and survivor's guilt is a common aspect of processing traumatic experiences and can be an important step in healing.
B. "I keep having flashbacks about when I was attacked by my neighbor."
Rationale: This statement indicates that the client is acknowledging and discussing the flashbacks related to the traumatic event. Progression toward positive outcomes in posttraumatic stress disorder (PTSD) often involves recognizing and addressing distressing symptoms.
C. "I prefer to go through the recovery process independently."
The preference for independence may indicate resistance to seeking support, which can hinder progress in addressing and managing PTSD symptoms.
D. "I think my experience has affected my ability to trust others."
Recognizing that the traumatic experience has affected the ability to trust others reflects insight into the impact of the trauma on relationships, which is a step toward positive outcomes.
Full Explanation
Choice A rationale:
Expressing feelings of guilt and survivor's guilt is a common aspect of processing traumatic experiences and can be an important step in healing.
Choice B rationale:
Rationale: This statement indicates that the client is acknowledging and discussing the flashbacks related to the traumatic event. Progression toward positive outcomes in posttraumatic stress disorder (PTSD) often involves recognizing and addressing distressing symptoms.
Choice C rationale:
The preference for independence may indicate resistance to seeking support, which can hinder progress in addressing and managing PTSD symptoms.
Choice D rationale:
Recognizing that the traumatic experience has affected the ability to trust others reflects insight into the impact of the trauma on relationships, which is a step toward positive outcomes.
A nurse is creating a plan of care for a client who has antisocial personality disorder. Which of the following interventions should the nurse include?
A. Appoint the client to be the leader during group therapy.
Appointing the client as a leader may not be appropriate, as individuals with antisocial personality disorder may misuse their position of authority.
B. Monitor the client's interactions with other clients.
Clients with antisocial personality disorder often struggle with interpersonal relationships, may be manipulative, and may engage in behaviors that violate the rights of others. Monitoring the client's interactions with other clients helps ensure a safe and therapeutic environment while preventing harm to others.
C. Offer the client two warnings before implementing consequences.
Offering warnings before consequences might not be effective with clients who have antisocial personality disorder, as they may disregard rules and consequences.
D. Assign the client to a room near the activity area.
Assigning a room near the activity area does not necessarily address the need to monitor the client's interactions with others.
Full Explanation
Choice A rationale:
Appointing the client as a leader may not be appropriate, as individuals with antisocial personality disorder may misuse their position of authority.
Choice B rationale:
Clients with antisocial personality disorder often struggle with interpersonal relationships, may be manipulative, and may engage in behaviors that violate the rights of others. Monitoring the client's interactions with other clients helps ensure a safe and therapeutic environment while preventing harm to others.
Choice C rationale:
Offering warnings before consequences might not be effective with clients who have antisocial personality disorder, as they may disregard rules and consequences.
Choice D rationale:
Assigning a room near the activity area does not necessarily address the need to monitor the client's interactions with others.
A nurse is instructing a client about medications that can cause erectile dysfunction. Which of the following medications should the nurse include in the teaching?
A. Sertraline
Sertraline is an antidepressant medication known as a selective serotonin reuptake inhibitor (SSRI). One of the potential side effects of SSRIs is sexual dysfunction, including erectile dysfunction.
B. Vancomycin
Vancomycin is an antibiotic and is not typically associated with erectile dysfunction.
C. Topiramate
Topiramate is an anticonvulsant medication and is not typically associated with erectile dysfunction.
D. Polyethylene glycol
Polyethylene glycol is a laxative and is not typically associated with erectile dysfunction.
Full Explanation
Choice A rationale:
Sertraline is an antidepressant medication known as a selective serotonin reuptake inhibitor (SSRI). One of the potential side effects of SSRIs is sexual dysfunction, including erectile dysfunction.
Choice B rationale:
Vancomycin is an antibiotic and is not typically associated with erectile dysfunction.
Choice C rationale:
Topiramate is an anticonvulsant medication and is not typically associated with erectile dysfunction.
Choice D rationale:
Polyethylene glycol is a laxative and is not typically associated with erectile dysfunction.