A patient admitted to the medical-surgical unit was recently weaned from a mechanical ventilator and an IV infusion of lorazepam.
The patient has been alert and oriented for 24 hours but is now experiencing confusion.
The practical nurse assists the registered nurse with the evaluation of new-onset confusion by assessing the patient’s sense of place and time, difficulty focusing, short-term memory loss, and increased lethargy.
What condition does the practical nurse suspect in this patient?
Psychosis.
Dementia.
Amnesia.
Delirium.
The Correct Answer is D
Choice D rationale
Delirium is a sudden onset of confusion that can be caused by a variety of factors, including withdrawal from certain medications like lorazepam. Symptoms can include disorientation, difficulty focusing, short-term memory loss, and increased lethargy.
Choice A rationale
Psychosis is a severe mental disorder characterized by a disconnection from reality. It often involves hallucinations or delusions, which are not mentioned in the scenario.
Choice B rationale
Dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury. It is marked by memory disorders, personality changes, and impaired reasoning. It typically does not have a sudden onset.
Choice C rationale
Amnesia is a condition in which one’s memory is lost or disturbed. It can be caused by brain injury or severe emotional trauma. The scenario does not provide information suggesting the patient has experienced a loss of memory.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Monitoring mental status is important, but it is not the priority nursing action in this situation. The individual has been found after being missing for 48 hours and the immediate concern should be their physical well-being.
Choice B rationale
Encouraging the individual to recall recent events may be part of the assessment process, but it is not the priority nursing action. The individual’s physical health could be at risk after being outside for an extended period, and this should be addressed first.
Choice C rationale
Assessing vital signs is the priority nursing action. The individual has been found after being missing for 48 hours, potentially exposed to harsh weather conditions and without access to food or water. It is crucial to assess their physical state as they may be dehydrated, hypothermic, or have other immediate health concerns.
Choice D rationale
Contacting family members is important for providing information and support, but it is not the priority nursing action. The first concern should be to assess and stabilize the individual’s physical condition.
Correct Answer is A
Explanation
The correct answer is Choice A.
When communicating with an angry patient, the nurse must first listen actively. Active listening allows the nurse to identify the key issues and work through them methodically.
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