Chapter 23-B Delirium

Delirium

The nurse discusses the common causes of delirium in adolescents with a group of parents in the community.

Which adolescent condition, if listed by the parents, should indicate to the nurse the need for further teaching?

A. Tendency toward impulsive, risk-taking behaviors

B. Drug and substance abuse and withdrawal

C. A febrile illness

D. Head trauma as a result of participation in contact sports

A. Tendency toward impulsive, risk-taking behaviors

B. Drug and substance abuse and withdrawal

C. A febrile illness

D. Head trauma as a result of participation in contact sports

The nurse is caring for a patient who is diagnosed with delirium.

Which assessment finding indicates to the nurse that the patient's diagnosis is correct?

A. Lack of ability to remember recent events leading up to hospitalization

B. Desire to discuss their opinion on why delirium started

C. Obsessive correctness and efficiency with tasks

D. Sleeping heavily night and day

A. Lack of ability to remember recent events leading up to hospitalization

B. Desire to discuss their opinion on why delirium started

C. Obsessive correctness and efficiency with tasks

D. Sleeping heavily night and day

A patient who is experiencing postanesthesia delirium keeps saying that they are talking to their deceased grandmother. The patient's husband says, "My wife is blessed."

How should the nurse respond?

A. "I don't know why your wife would think she's talking to her grandmother. That is simply the anesthetic medications talking."

B. "I understand you are pleased, but for your wife's safe recovery, we should reorient her to the present surroundings."

C. "I once dreamed that I also spoke with a deceased relative who was important to me."

D. "Your wife is not talking to her grandmother."

A. "I don't know why your wife would think she's talking to her grandmother. That is simply the anesthetic medications talking."

B. "I understand you are pleased, but for your wife's safe recovery, we should reorient her to the present surroundings."

C. "I once dreamed that I also spoke with a deceased relative who was important to me."

D. "Your wife is not talking to her grandmother."

The spouse of a patient who is diagnosed with delirium expresses concern about how to best deal with the patient's confusion. The nurse teaches the spouse about nonpharmacologic interventions that may benefit the patient.

Which statement by the patient's spouse should concern the nurse?

A. "I am always on the lookout for safety hazards in the environment."

B. "I reorient my spouse to person, place, and time every morning."

C. "Sometimes my spouse will refuse to eat for several days."

D. "I try to maintain as consistent a schedule as I can."

A. "I am always on the lookout for safety hazards in the environment."

B. "I reorient my spouse to person, place, and time every morning."

C. "Sometimes my spouse will refuse to eat for several days."

D. "I try to maintain as consistent a schedule as I can."

The nurse is caring for an older adult patient. In less than an hour, the patient becomes progressively disoriented, agitated, and confused.

Which diagnostic test should the nurse expect would most likely be ordered for the patient?

A. Electrocardiogram (ECG)

B. Head computerized tomography (CT) scan

C. Abdominal x-ray

D. Urine culture and sensitivity

A. Electrocardiogram (ECG)

B. Head computerized tomography (CT) scan

C. Abdominal x-ray

D. Urine culture and sensitivity

The nurse is examining the chart of a patient suspected of having delirium.

Which test provides the most information on mental status?

A. Hemoglobin and hematocrit levels

B. Blood urea nitrogen (BUN) and creatinine levels

C. Magnetic resonance imaging (MRI)

D. Confusion Assessment Method (CAM) test

A. Hemoglobin and hematocrit levels

B. Blood urea nitrogen (BUN) and creatinine levels

C. Magnetic resonance imaging (MRI)

D. Confusion Assessment Method (CAM) test

A patient who is diagnosed with delirium keeps getting out of bed and has frantic outbursts searching through their room and wandering the halls.

Which intervention is appropriate for the nurse to assign to prevent injury?

A. Assigning a sitter to the patient's bedside

B. Keeping lighting and noise levels to a minimum

C. Limiting the patient's visitors

D. Obtaining an order for soft restraints

A. Assigning a sitter to the patient's bedside

B. Keeping lighting and noise levels to a minimum

C. Limiting the patient's visitors

D. Obtaining an order for soft restraints

The nurse is caring for a patient who is diagnosed with delirium. The patient's spouse asks the nurse, "What is causing the delirium?"

How should the nurse respond?

A. "Impaired neurotransmitter action in the brain is thought to cause delirium."

B. "Delirium results from bipolar disorder."

C. "It is believed that delirium is most likely caused by smoking for many years."

D. "We know for a fact that pancreatitis causes delirium."

A. "Impaired neurotransmitter action in the brain is thought to cause delirium."

B. "Delirium results from bipolar disorder."

C. "It is believed that delirium is most likely caused by smoking for many years."

D. "We know for a fact that pancreatitis causes delirium."

The nurse admits a woman who is diagnosed with delirium. Her adult daughter is present.  

Which specific question should the nurse ask the daughter in an attempt to determine the cause of the delirium?

A. "Does your mother have a history of drug or alcohol abuse?"

B. "Has your mother been exposed to radiation?"

C. "Does your mother exercise regularly?"

D. "Does your family have a history of delirium?"

A. "Does your mother have a history of drug or alcohol abuse?"

B. "Has your mother been exposed to radiation?"

C. "Does your mother exercise regularly?"

D. "Does your family have a history of delirium?"

The nurse is planning care for a patient who is diagnosed with delirium.

Which cognitive intervention is appropriate?

A. Administering oxygen

B. Providing nutrition

C. Reorienting to time and place

D. Monitoring intravenous fluids

A. Administering oxygen

B. Providing nutrition

C. Reorienting to time and place

D. Monitoring intravenous fluids

A patient presents in the emergency department with a flushed and diaphoretic appearance. The nurse suspects the patient is experiencing delirium.

Which additional observation supports the nurse's suspicion?

A. Dry skin

B. Focusing on an assigned task

C. Purposeful activity

D. Rambling speech

A. Dry skin

B. Focusing on an assigned task

C. Purposeful activity

D. Rambling speech

The adult children of a patient experiencing delirium ask the nurse, "Is there anything we can do to improve our parent's delirium?"

Which strategy should the nurse include in the response to the family's question?

A. "Make sure your parent eats a low-fat diet."

B. "Encourage your parent to develop new hobbies."

C. "Try to maintain a stable, familiar, nonstimulating environment."

D. "Take your parent out to new places every day."

A. "Make sure your parent eats a low-fat diet."

B. "Encourage your parent to develop new hobbies."

C. "Try to maintain a stable, familiar, nonstimulating environment."

D. "Take your parent out to new places every day."

The nurse assigns the nursing diagnosis of Injury, Risk for for a patient who is diagnosed with delirium.

Which intervention should the nurse include in the patient's plan of care?

A. Limiting visitors

B. Keeping lighting and noise levels low

C. Putting a bed alarm on the patient's bed

D. Instituting soft restraints for the patient

A. Limiting visitors

B. Keeping lighting and noise levels low

C. Putting a bed alarm on the patient's bed

D. Instituting soft restraints for the patient

The nurse examines the chart of a newly admitted patient who is confused. The healthcare provider suspects that the patient has delirium.

Which test should the nurse expect to be ordered to help confirm the suspected diagnosis?

A. Drug and alcohol screening

B. Computerized tomography (CT) scan

C. Stress test

D. Magnetic resonance imaging (MRI

A. Drug and alcohol screening

B. Computerized tomography (CT) scan

C. Stress test

D. Magnetic resonance imaging (MRI

The nurse admits an older adult patient suspected of having delirium.

Which order should the nurse expect the healthcare provider to prescribe first for the patient?

A. Psychiatric testing

B. Bedrest

C. Placing the patient in soft restraints

D. Lab work to determine the presence of underlying medical condition

A. Psychiatric testing

B. Bedrest

C. Placing the patient in soft restraints

D. Lab work to determine the presence of underlying medical condition

The nurse is evaluating the care of a patient who is diagnosed with delirium.

Which finding indicates to the nurse that the treatment has been successful?

A. The patient is oriented to person.

B. The patient is able to perform activities of daily living (ADLs).

C. The patient experiences fewer mood swings than before.

D. The patient is difficult to communicate with.

A. The patient is oriented to person.

B. The patient is able to perform activities of daily living (ADLs).

C. The patient experiences fewer mood swings than before.

D. The patient is difficult to communicate with.

The nurse is teaching a new nurse about postanesthesia delirium.

Which statement by the new nurse reflects effective teaching?

A. "Delirium is a permanent condition."

B. "Delirium will evolve into dementia."

C. "Delirium is a temporary condition."

D. "Delirium resolves within 72 hours.

A. "Delirium is a permanent condition."

B. "Delirium will evolve into dementia."

C. "Delirium is a temporary condition."

D. "Delirium resolves within 72 hours.

The nurse is conducting an assessment for a patient who is diagnosed with delirium.

Which risk factor noted in the patient's health history may have caused the current diagnosis?

A. History of anorexia nervosa

B. Recent opioid use

C. Diet high in fiber

D. History of hypertension

A. History of anorexia nervosa

B. Recent opioid use

C. Diet high in fiber

D. History of hypertension

The nurse is seeing a pregnant patient in the emergency department who presents with symptoms of delirium.

Which condition should the nurse suspect the patient is experiencing?

A. Placenta abruptio

B. Placenta previa

C. HELLP syndrome

D. Imminent birth

A. Placenta abruptio

B. Placenta previa

C. HELLP syndrome

D. Imminent birth

The healthcare provider has determined that a patient's delirium is being caused by severe depression. The patient's family asks the nurse, "Is there a medication that can help our parent?"

Which class of medications should the nurse list as being ordered to minimize the patient's delirium?

A. Proton pump inhibitors (PPIs)

B. Antipsychotics

C. Selective serotonin reuptake inhibitors (SSRIs)

D. Beta blockers

A. Proton pump inhibitors (PPIs)

B. Antipsychotics

C. Selective serotonin reuptake inhibitors (SSRIs)

D. Beta blockers

The nurse is teaching care to the husband of a patient diagnosed with delirium.

Which statement by the husband indicates understanding of delirium care?

A. "I will continue to remind myself that this condition is temporary."

B. "My wife should be offered multiple choices for activity participation."

C. "We should change our daily schedule frequently."

D. "I will remember to allow her to eat until she decides she is full."

A. "I will continue to remind myself that this condition is temporary."

B. "My wife should be offered multiple choices for activity participation."

C. "We should change our daily schedule frequently."

D. "I will remember to allow her to eat until she decides she is full."

The wife of a patient who is diagnosed with delirium tells the nurse that her healthcare provider suggested trying herbal supplements for her husband to ease the delirium.

How should the nurse respond?

A. "Actually, some studies have shown that melatonin may have a preventive effect on delirium."

B. "That is a great idea. I would try feverfew first."

C. "Herbs can be dangerous. I wouldn't suggest that you do it."

D. "I'm sure your healthcare provider thought of this and knows what is best for your husband."

A. "Actually, some studies have shown that melatonin may have a preventive effect on delirium."

B. "That is a great idea. I would try feverfew first."

C. "Herbs can be dangerous. I wouldn't suggest that you do it."

D. "I'm sure your healthcare provider thought of this and knows what is best for your husband."

The nurse is planning discharge teaching for the family of a patient who is diagnosed with delirium.

Which strategy to prevent or improve delirium is appropriate for the nurse to include in the teaching?

A. Increasing stimulation after meals

B. Enrolling the patient in an aerobic exercise class

C. Encouraging the patient to develop new skills and meet new friends

D. Promoting consistency in the patient's routine

A. Increasing stimulation after meals

B. Enrolling the patient in an aerobic exercise class

C. Encouraging the patient to develop new skills and meet new friends

D. Promoting consistency in the patient's routine

A patient is diagnosed with delirium. In the end-of-shift report, the nurse states that the patient was lucid all day but became increasingly confused in the evening and at bedtime.

Which explanation should the nurse attribute to the patient's behavior?

A. The patient needs to be restrained.

B. The patient has taken an overdose of medication.

C. The patient's delirium is progressing to Alzheimer disease.

D. The patient is experiencing sundowning.

A. The patient needs to be restrained.

B. The patient has taken an overdose of medication.

C. The patient's delirium is progressing to Alzheimer disease.

D. The patient is experiencing sundowning.

The nurse is performing discharge teaching for a patient who is diagnosed with delirium. The nurse instructs the family on ways to care for the patient at home.

Which intervention is important for the nurse to include in the teaching?

A. Allowing to patient to eat as much or as little as they want

B. Providing the patient with a variety of activities

C. Providing reassurance that the delirium is temporary

D. Creating a stimulating daily schedule

A. Allowing to patient to eat as much or as little as they want

B. Providing the patient with a variety of activities

C. Providing reassurance that the delirium is temporary

D. Creating a stimulating daily schedule