The nurse is caring for an older adult client who is experiencing delirium. Which of the following should be the priority action by the nurse?

Administer diazepam.

Obtain a medical history.

Start intravenous fluids.

Raise 3 of the 4 side rails of the bed.

Answer and Explanation

The Correct Answer is B

A. Administer diazepam: This is not a first-line treatment for delirium and could exacerbate confusion or sedation, potentially worsening delirium.

B. Obtain a medical history: Delirium is often caused by underlying medical conditions such as infections, electrolyte imbalances, or medication side effects. Obtaining a medical history is crucial for identifying and treating the underlying cause, making it the priority action.

C. Start intravenous fluids: While IV fluids might be necessary in cases of dehydration or electrolyte imbalances, identifying the underlying cause of delirium through medical history is more urgent.

D. Raise 3 of the 4 side rails of the bed: This action may help prevent falls but does not address the underlying cause of delirium. Moreover, the use of side rails can sometimes increase the risk of injury or entrapment.

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Correct Answer is C

Explanation

A. "I just don't remember what I did this morning." This statement reflects an inability to recall the events of the morning, which is a common symptom in Alzheimer's disease but does not constitute confabulation. It simply indicates memory loss.

B. "This morning, this morning, this morning..." Repetition of words or phrases can indicate a language or communication issue often seen in Alzheimer's disease but is not an example of confabulation. It may reflect confusion or perseverance.

C. "It was good. The Queen of England visited me there." Confabulation involves the creation of false memories or statements to fill in gaps in memory. The client's statement about the Queen of England visiting is a fabricated or distorted memory and is an example of confabulation. This choice is correct.

D. "Snip, snap. Take a nap." This phrase is nonsensical and may indicate disorganized thinking or speech, which can occur in Alzheimer's disease, but it is not an example of confabulation. It does not fill a memory gap with a fabricated story. Therefore, this choice is incorrect.

A. Medication side effects B. Hypothyroidism C. Vitamin B12 deficiency D. Multiple small brain infarcts

Correct Answer is ["A","B","C"]

Explanation

A. Medication side effects: Certain medications can cause cognitive impairment that mimics dementia, but this condition is often reversible if the medication is adjusted or discontinued.

B. Hypothyroidism: Hypothyroidism can lead to cognitive impairment that may be reversible with appropriate thyroid hormone replacement therapy.

C. Vitamin B12 deficiency: Deficiency in vitamin B12 can cause cognitive deficits that are often reversible with supplementation.

D. Multiple small brain infarcts: This condition, often associated with vascular dementia, usually leads to permanent brain damage and is typically not reversible.

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The nurse is caring for an older adult client who is experiencing delirium. Which of the following should be the priority action by the nurse?

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