The nurse is reviewing the nurses notes admission assessment, vital sign 5. and laboratory data.
Complete the following sentence by using the list of options.
The nurse should first plan to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Prioritizing interventions for an older adult ICU client experiencing acute delirium secondary to suspected postoperative infection (likely sepsis from an infected hip surgical site) is an essential component of care. The client shows classic delirium features including disorientation, hallucinations, agitation, and fluctuating cognition. Management requires addressing the underlying cause (infection) while simultaneously reducing environmental stimuli to prevent worsening confusion. Priority care follows both medical stabilization and supportive environmental control.
Rationale for correct choices:
• Contact the provider for an antibiotic prescription: The client’s fever, hypotension, elevated WBC count, and infected surgical wound with purulent drainage strongly indicate a postoperative wound infection progressing toward sepsis. Infection is a major reversible cause of delirium, so treating the underlying cause is the highest priority. Antibiotic therapy is essential to control infection and prevent further systemic deterioration. Without treating the infection, delirium will persist or worsen.
• Dim the lights: Delirious clients benefit from a calm, low-stimulation environment to reduce sensory overload and agitation. Bright lighting, noise, and excessive stimulation can worsen confusion and hallucinations. Dim lighting helps promote rest and orientation while reducing anxiety and behavioral disturbances. This intervention supports safety and cognitive stabilization.
Rationale for incorrect choices:
• Ask the client’s partner to leave the room: Family presence is often protective in delirium because familiar individuals provide orientation, reassurance, and emotional stability. Removing the partner could worsen agitation, fear, and disorientation. The client already shows severe confusion and hallucinations, making familiar support beneficial.
• Increase the volume on the television: Increasing sensory stimulation is contraindicated in delirium because it can worsen confusion and agitation. Loud or excessive auditory input increases cognitive overload and may intensify hallucinations. The client already demonstrates severe perceptual disturbances, so additional stimulation is harmful. This action would worsen rather than improve the condition.
• Place the client in 4-point restraints: Restraints are a last-resort intervention and are not appropriate for initial management of delirium. They can increase agitation, risk of injury, and worsen confusion, especially in older adults. Restraints do not address the underlying cause of delirium or promote reorientation. Less restrictive interventions such as environmental modification should always be attempted first.
• Assist with elimination: Assisting with elimination is a basic nursing need, but it is not a priority intervention for acute delirium management in this scenario. The client is experiencing severe confusion, hallucinations, and agitation secondary to likely sepsis, which requires stabilization of infection and environmental control first. While toileting needs should always be addressed, it does not directly improve the acute neurocognitive disturbance or safety risks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","F"]
Explanation
This case focuses on identifying risk factors contributing to delirium in an older adult postoperative ICU client. Delirium is commonly triggered by acute illness, infection, surgery, and underlying chronic conditions that affect brain resilience. Sensory deficits and environmental changes also significantly increase susceptibility. Recognizing predisposing and precipitating factors is essential for early prevention and management of acute cognitive decline.
Rationale for correct choices:
• Older adult status with recent surgery, ICU admission, fever, hypotension, and hip arthroplasty
Advanced age is a major risk factor for delirium due to decreased physiological reserve and brain vulnerability. Recent major surgery such as total hip arthroplasty increases risk due to anesthesia effects, pain, and immobility. The presence of fever and hypotension suggests systemic infection (likely sepsis), which is a strong precipitating factor for delirium. ICU admission further increases risk due to sleep disruption, invasive monitoring, and environmental stressors.
• Past medical history (hypertension, congestive heart failure, Parkinson’s disease): Chronic neurological and cardiovascular conditions increase vulnerability to altered cerebral perfusion and cognitive dysfunction. Parkinson’s disease specifically affects dopamine pathways, making patients more susceptible to confusion and hallucinations. Congestive heart failure may reduce oxygen delivery to the brain, contributing to cognitive changes. These conditions collectively lower the threshold for delirium development.
• Social history (visual loss, no glasses, hearing impairment): Sensory deprivation is a major modifiable risk factor for delirium. Visual and hearing impairments reduce environmental awareness and increase misinterpretation of stimuli. Not having glasses further worsens disorientation and confusion in a hospital setting. Even with hearing aids, older adults may still experience impaired processing, increasing vulnerability to cognitive decline.
Rationale for incorrect finding:
• Client is alert and oriented to person, place, and time: At baseline, this indicates intact cognitive function rather than a risk factor. While important for comparison, it does not contribute to delirium development. This statement reflects the client’s prior stable mental status before acute changes occurred.
Correct Answer is ["A","B","C","D","E","G","H"]
Explanation
The client is demonstrating acute delirium in the ICU, likely related to severe infection (possible postoperative wound infection progressing to sepsis), hypoxia risk, and multiple sensory impairments such as visual and hearing loss. Delirium is characterized by fluctuating confusion, disorientation, hallucinations, and altered attention. Management focuses on identifying and treating the underlying cause while providing a calm, structured, and orienting environment. Nursing interventions prioritize safety, reorientation, sensory support, and emotional reassurance.
Rationale:
A. Maintaining a well-lit environment helps reduce visual misinterpretations and hallucinations commonly seen in delirium. Adequate lighting decreases shadows that may be misinterpreted as threatening stimuli, especially in clients with visual impairment. A stable, well-lit setting promotes orientation and reduces anxiety and agitation.
B. Reorienting the client often is essential because delirium involves fluctuating confusion and disorganized thinking. Frequent reminders of time, place, and situation help reduce disorientation and anxiety. Consistent reorientation supports cognitive grounding and helps the client regain awareness of reality.
C. Requesting that the client have the same caregivers with every shift promotes consistency and familiarity, which helps reduce confusion and agitation. Continuity of care decreases environmental stressors and improves trust in caregivers. This is especially beneficial in delirious clients who struggle with frequent changes in staff and routine.
D. Asking the client's partner to stay with the client as much as possible provides comfort, familiarity, and emotional reassurance. Family presence can reduce agitation, improve orientation, and help calm hallucinations or delusional thinking. Familiar voices and presence are grounding factors in delirium management.
E. Requesting that the client's family bring eyeglasses from home addresses sensory deprivation, which can worsen delirium. Visual impairment increases misinterpretation of surroundings and contributes to hallucinations. Restoring vision improves environmental awareness and helps the client interpret reality more accurately.
F. Providing detailed information about what to expect during care is not appropriate during acute delirium because the client has impaired attention and cognition. Complex explanations may increase confusion and agitation rather than reduce it. Education is more appropriate once delirium resolves and cognition stabilizes.
G. Writing the full date on the client's whiteboard helps reinforce orientation to time, which is commonly impaired in delirium. Visual cues serve as constant reminders of current temporal context and support cognitive reorientation. This simple environmental modification is an effective non-pharmacological intervention.
H. Acknowledging the client’s feelings is therapeutic because it validates emotional distress without reinforcing hallucinations or delusions. This helps reduce anxiety and agitation while maintaining trust between the nurse and client. Emotional support is a key component of delirium management alongside reorientation and safety measures.
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