A nurse is caring for a group of older adult clients. Which of the following
manifestations indicates one of the clients is experiencing delirium?
A. A client wants to know the current time while there is a clock on the wall.
B. A client attempts to climb out of bed and repeatedly states she must get
home.
C. A client requests extra blankets when the thermostat in the room indicates
25.6 Degrees C (78 F).
D. A client refuses to get out of bed and has no motivation to attend to daily
hygiene. -Correct Answer= B.
(Delirium is characterized by a change in cognition that occurs over a short
period of time. It results from a secondary physiological condition (e.g.,
infection, surgery, prolonged hospitalization, hypoxia, fever, medications)
and is a transient disorder. Although delirium can occur with any age, it is
more common in older adults. It frequently progresses in the evening hours
and is sometimes called "sundown syndrome." Delirium is characterized by
alterations in memory, agitation, restlessness, illusions, or hallucinations. A
client who becomes acutely confused and agitated may be showing
manifestations of delirium.)
A community health nurse is providing teaching to the family of a client who
has primary dementia. Which of the following manifestations should the
nurse tell the family to expect?
A. Decreased auditory and visual acuity.
B. Decreased display of emotion.
C. Personality traits that are opposite of original traits.
D. Forgetfulness gradually progressing to disorientation. -Correct Answer= D.
(Dementia usually appears first as forgetfulness. Other manifestations may
be apparent only upon neurologic examination or cognitive testing. Loss of
functioning progresses slowly from impaired language skills and difficulty
with ordinary daily activities to severe memory loss and complete
disorientation with withdrawal from social interaction.)
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