Nokea
Which client would have an increased risk for delirium?
- A. An elderly woman with abdominal pain
- B. A 3-year-old child with a temperature of 103.2 F
- C. A middle-aged woman newly diagnosed with multiple sclerosis
- D. A young adult male with gastroenteritis and dehydration
Correct Answer: B
Rationale: High fever in young children significantly increases the risk of delirium, more so than the other conditions listed.
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A client with dementia is starting pharmacotherapy to slow the progression of cognitive decline. The client has a history of moderate but steady alcohol use over the past 45 years. Which medication should the nurse question as least suitable for this client?
- A. Tacrine (Cognex)
- B. Memantine (Namenda)
- C. Donepezil (Aricept)
- D. Rivastigmine (Exelon)
Correct Answer: A
Rationale: Tacrine is less suitable due to its high risk of liver toxicity, particularly concerning given the client's history of alcohol use.
A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client approaches the nurse and states, 'I'm going to take a walk outside. I'll be back in about 10 minutes.' Which is the most appropriate nursing action?
- A. Further assess the client's motives for wanting to walk.
- B. Give the client permission to go on a walk on the grounds.
- C. Tell the client the walk is not allowed and restrict him to the unit.
- D. Designate a staff member to accompany the client on the walk.
Correct Answer: D
Rationale: Accompanying the client ensures safety due to the risk of disorientation in delirium.
The caregiver of a client with Alzheimer's disease reports to the nurse that often the client will suddenly become angry during meals and nothing seems to calm him down. The nurse teaches the caregiver to use distraction techniques. Which response would be best to teach as an example of this technique?
- A. Let's look at what is on television.
- B. If you stop yelling, I will get your dessert.
- C. Don't you want to finish your meal?
- D. I don't understand what you are saying.
Correct Answer: A
Rationale: Distraction, such as watching television, redirects the client's focus and helps de-escalate agitation.
The nurse is working with a client who has hallucinations and delusions. The client tells the nurse she cannot take a shower because she is waiting for her husband to take her home. Which response by the nurse is best in this situation?
- A. It would be best if you just took your shower now.
- B. You seem anxious and upset.
- C. You have plenty of time to shower before it's time to go home.
- D. Why are you thinking you're going home?
Correct Answer: C
Rationale: Going along with the delusion without reinforcing it allows the client to proceed with activities calmly.
Which is believed to be a risk factor specific to the development of delirium?
- A. Increased severity of physical illness
- B. Older age
- C. Baseline cognitive impairment
- D. Gradual decline in functioning
Correct Answer: A
Rationale: Increased severity of physical illness is a primary trigger for delirium, unlike gradual decline, which is characteristic of dementia.