When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?

Correct Answer: C

Rationale: The correct answer is C: Medications the patient has recently taken. This information is crucial because certain medications can cause symptoms of delirium or exacerbate confusion in elderly patients. By reviewing the patient's recent medications, healthcare providers can identify potential drug-induced causes of confusion and adjust the treatment accordingly. Choice A (Evidence of spasticity or flaccidity) is incorrect because these symptoms are more related to neurological conditions such as stroke or spinal cord injury, not specifically delirium. Choice B (The patient’s level of motor activity) is not as relevant in distinguishing delirium from other problems as medication history, as motor activity can be influenced by various factors. Choice D (Level of preoccupation with somatic symptoms) is also less relevant compared to medication history in differentiating delirium, as somatic symptoms may not always directly indicate the underlying cause of confusion in elderly patients.

Correct Answer: D

Rationale: The correct answer is D: Losing control over her emotions. The teen's statement indicates a fear of losing control if she starts crying. This fear suggests that she believes crying will lead to an inability to stop, indicating a concern about managing her emotions. This fear of losing control over her emotions aligns with the teen's hesitance to express her grief through tears. A: Appearing emotionally immature - This choice is incorrect as the teen's statement does not directly suggest a fear of appearing emotionally immature. B: Embarrassing herself by crying in public - This choice is incorrect as the teen's statement does not mention a fear of embarrassment. C: Losing the support of her friends and family - This choice is incorrect as the teen's statement does not indicate a fear of losing support from others.

Correct Answer: D

Rationale: The correct answer is D: Adventitious crisis. This type of crisis is triggered by external events such as moving to a retirement center after 50 years in the same home. The sudden change in environment can lead to distress and challenges for the elderly couple, causing an adventitious crisis. Acute grief (A) and traumatic grief (B) are typically associated with the loss of a loved one, not a change in lifestyle. Chronic sorrow (C) refers to ongoing grief related to a chronic illness or disability, which is not the case in this scenario.

Correct Answer: D

Rationale: The correct answer is D because it acknowledges the patient's discomfort without making assumptions or judgments. By recognizing the difficulty the patient is facing and offering to discuss it when they are ready, the nurse shows empathy and respect for the patient's feelings. Choice A is incorrect because it assumes the family is a problem for the patient. Choice B is incorrect because it focuses on expressing negative feelings rather than addressing the patient's current discomfort. Choice C is incorrect because it deflects the conversation to the physician without addressing the patient's immediate needs.

Correct Answer: D

Rationale: The correct answer is D because it accurately reflects the typical memory impairment after ECT treatments. ECT affects both recent and remote memory, leading to profound confusion and cognitive difficulties. This is due to the disruption of neural pathways involved in memory consolidation and retrieval. Choice A is incorrect as ECT does have predictable effects on memory. Choice B is incorrect because patients typically have more difficulty with recent memory than remote memory. Choice C is also incorrect as patients usually experience more than just mild difficulty remembering recent events; the memory impairment is more severe than just forgetting what was eaten for breakfast.

Correct Answer: C

Rationale: The correct answer is C: Having positive self-esteem. This is unrelated to depression as depression typically involves feelings of worthlessness and low self-esteem. A: Crying and refusing tasks, B: Answering "I forgot to" questions, and D: Neglecting ADLs are all commonly associated symptoms of depression such as apathy, memory issues, and lack of motivation for self-care. Therefore, choice C stands out as the symptom unrelated to depression due to its contradiction with the typical manifestations of the condition.

Correct Answer: D

Rationale: The correct answer is D because focusing on the feelings suggested by the delusion can help the patient process and manage their emotions underlying the delusion. By addressing the emotions, the nurse can help the patient gain insight into the delusion and reduce its intensity. Confronting the delusion (A) may lead to resistance and reinforcement. Refuting the delusion with logic (B) may further alienate the patient. Exploring reasons for the delusion (C) may not directly address the emotional component.

Correct Answer: A

Rationale: The correct answer is A because suicide assessment must continue throughout the ECT course to ensure the safety and well-being of the client. During ECT, the client may experience changes in mood and behavior, which could impact their risk of suicide. It is essential for the nurse to monitor and assess the client's suicidal ideation and intent regularly. This ongoing assessment helps in identifying any exacerbation of suicidal thoughts and allows for timely intervention to prevent self-harm. Choice B is incorrect because antidepressant medications are not necessarily contraindicated throughout the ECT course. In some cases, a client may still require antidepressants in addition to ECT for optimal treatment outcomes. Choice C is incorrect because it is important to acknowledge and validate the client's feelings of hopelessness rather than discouraging them. By addressing and exploring these feelings, the nurse can provide support and facilitate the client's emotional processing. Choice D is incorrect because encouraging a high-caloric diet is not directly related to the critical intervention needed during

Correct Answer: B

Rationale: The correct answer is B because it emphasizes the nurse's role in actively working with the patient to address interpersonal problems. The nurse's initial role is to provide support and assistance to the patient in resolving their issues collaboratively. Choice A focuses on medical treatment and collaboration with the doctor, not specifically addressing interpersonal problems. Choice C solely emphasizes the role of medications in improving the patient's well-being, neglecting the interpersonal aspect. Choice D suggests passing off the responsibility to other professionals, which contradicts the nurse's initial role as a source of help for the patient. In summary, choice B is correct because it highlights the nurse's active involvement in solving the patient's interpersonal problems.