Which assessment findings would the nurse expect in a patient experiencing delirium?
a. Impaired level of consciousness
b. Disorientation to place, time
c. Wandering attention
d. Apathy
e. Agnosia
ANS: A, B, C
Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.
You might also like to view...
A student nurse learns that the spleen has several functions. What functions do they include? (Select all that apply.)
a. Breaks down hemoglobin b. Destroys old or defective red blood cells (RBCs) c. Forms vitamin K for clotting d. Stores extra iron in ferritin e. Stores platelets not circulating
The nurse is conducting preoperative teaching with the patient and family. The nurse teaches the patient the proper use of the incentive spirometer
The nurse knows that the patient understands the need for this intervention when the patient states, "I use this device to: a. help my cough reflex." b. expand my lungs after surgery." c. increase my lung circulation." d. keep me from coughing."
High-fat diets are known to be a leading cause of obesity in America. What are high-fat diets also implicated in?
A) Pancreatitis B) Insulin resistance C) Cystic fibrosis D) Liver disease
How are diversity and multiculturalism in the workplace different?
What will be an ideal response?