An 84-year-old patient has just returned from the post-anesthetic care unit after undergoing hip arthroplasty. The patient is only oriented to their name.
The patient’s family is distressed because the patient had no cognitive deficits before surgery.The patient is later diagnosed with postoperative delirium. What should the nurse communicate to the patient’s family?

This type of delirium is treatable and the patient’s cognition will return to its previous levels.

This issue can be resolved by administering antidotes to the anesthetic used in surgery.

Delirium involves a progressive decline in memory loss and overall cognitive function.

This problem is self-limiting and there is nothing to worry about.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Postoperative delirium is a common condition that can occur in older patients after surgery, especially major procedures like hip arthroplasty. It is characterized by a sudden onset of confusion and altered consciousness. This type of delirium is indeed treatable and most patients’ cognition will return to its previous levels. The treatment often involves addressing the underlying causes, such as pain, medication effects, or metabolic imbalances, and providing supportive care. It’s important for the family to understand that this is a temporary condition and does not indicate a permanent change in their loved one’s mental status.
Choice B rationale
While anesthetics can contribute to postoperative delirium, the condition is usually multifactorial and not solely due to the anesthetic used in surgery. Therefore, administering antidotes to the anesthetic is not typically how postoperative delirium is managed. Instead, the focus is on treating the underlying causes and providing supportive care.
Choice C rationale

Delirium does involve a disturbance in cognition, including memory impairment, but it does not involve a progressive decline in memory loss and overall cognitive function. That description is more characteristic of dementia, a different condition. Delirium is typically a temporary condition that improves once the underlying cause is addressed.
Choice D rationale
While postoperative delirium is often self-limiting, meaning it resolves on its own over time, it is not accurate to say there is nothing to worry about. Postoperative delirium can be distressing for the patient and their family, and in some cases, it can be associated with longer hospital stays and increased morbidity. Therefore, it is a condition that should be taken seriously and managed appropriately.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice C rationale
When providing care for a comatose patient, a nurse should evaluate motor responses by observing the patient’s response to painful stimuli. This can be done by applying a painful stimulus, such as a trapezius pinch or nailbed pressure, and observing the patient’s motor response. Purposeful or semi-purposeful movements, such as localizing or withdrawing from pain, can provide valuable information about the patient’s level of consciousness and neurological function.
Choice A rationale
The Romberg test is used to evaluate balance and is not typically used to evaluate motor responses in a comatose patient.
Choice B rationale
Assessing the patient’s sensitivity to temperature and touch can provide information about sensory function, but it does not directly evaluate motor responses.
Choice D rationale

Observing the reaction of pupils to light can provide information about cranial nerve function, but it does not directly evaluate motor responses.

A. Speak slowly and clearly using yes/no Questions one at a time. B. Ask the family member if they know what the client wants. C. Keep repeating the same ultiple times. D. Put a cell phone in their right hand to text their Questions.

Correct Answer is A

Explanation

Choice A rationale
Speaking slowly and clearly using yes/no questions one at a time can help facilitate communication with a client diagnosed with aphasia.
Choice B rationale

Asking a family member if they know what the client wants may not always be effective, as the client may have difficulty expressing their needs even to family members.
Choice C rationale
Repeating the same question multiple times may not be effective and could potentially frustrate the client.
Choice D rationale
Putting a cell phone in their right hand to text their questions assumes that the client has the ability to text, which may not be the case for all clients diagnosed with aphasia.

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Naxlex Comprehensive Predictor Exams

When providing care for a comatose patient, how should a nurse evaluate motor responses?

Correct Answer is C

Explanation

The nurse is caring for a client that has been diagnosed with aphasia. How can the nurse communicate effectively with the client?

Correct Answer is A

Explanation

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