Delirium Pearson NCLEX Questions
The parent of a child diagnosed with delirium states to the nurse, "I thought only old people get confused. Why is this happening to my child?" How should the nurse respond?
Answer: "children are at risk for delirium because they lack the reserves to deal with certain stressors Rationale: Children are at risk for delirium because they lack the functional reserves to deal with physiologic stressors. Often, any febrile illness can cause them to develop delirium. Manifestations of delirium in children are often confused with obstinate behavior. Physiologic issues usually cause children's delirium. The prevalence of delirium in hospitalized children is 10-30%. Next Question
The family of a client who is diagnosed with delirium asks the nurse, "Can you give us any pointers on how we can help our father with his delirium?" Which statement should the nurse include in the response? (Select all that apply.)
Answer: "make sure that your father has appropriate nutrition", "promote consistency in your father's schedule", "reassure your father that delirium is often temporary." Rationale: Providing appropriate nutrition is an example of a physical intervention, which targets biologic factors contributing to the delirium. Promoting consistency in schedule is an environmental intervention that helps minimize the likelihood of confusion. A period of delirium is not the time to introduce new activities. A cognitive intervention is reassuring the client that the delirium is temporary, which will contribute to comfort. The client with delirium should be reoriented frequently. Next Question
The family of a client who is diagnosed with delirium asks the nurse, "What is the best way to deal with our father when he makes delusional statements?" How should the nurse respond?
Answer: "when he is making delusional statements, try validating what exactly he needs" Rationale: Instead of ignoring or confronting a client making delusional statements, use validation techniques to determine if the delusional statement is reflecting some unmet need. The family can then meet that need. Challenging the delusional client has the potential to make the client anxious and might lead to agitation or aggressive behavior. OK
The family of a client who has recovered from a period of delirium states, "We are so glad that this episode is over because it was really scary to see Dad like that." How should the nurse respond?
Answer: "yes, but is important to know that your dad is at risk for future episodes of delirium" Rationale: Individuals who experienced one episode of delirium are at increased risk for future episodes. Teaching should emphasize the prevention, detection, and treatment of health issues that may precipitate other episodes of delirium. The first response does not address the future risk of developing delirium. An episode of delirium does not infer immunity. Vitamins do not protect one against delirium. Next Question
The nurse is planning care for a client who is diagnosed with delirium. Which nursing diagnosis is most appropriate for the nurse to assign?
Answer: communication, verbal, impaired Rationale: Clients who are diagnosed with delirium have problems with thought processes and speech patterns. Depending on the severity of the delirium, Communication: Verbal, Impaired might be an appropriate diagnosis. Delirium does not cause airway, coping, or grieving issues. (NANDA-I ©2014) Next Question
The nurse should assess a client diagnosed with delirium for which symptom? (Select all that apply.)
Answer: disorganized thoughts, altered sleep patterns, limited attention span Rationale: Common manifestations of delirium include reduced awareness indicated by a limited attention span, impaired thinking skills evidenced by disorganized thoughts, and changes in behavior evidenced by altered sleep patterns. Other signs include an inability to answer questions and difficulty in reading, writing, and understanding speech.
The nurse is admitting a client who is suspected of having delirium. The nurse should assess for which potential precipitating factor? (Select all that apply.)
Answer: infection, fracture or trauma, history of hypoglycemia Rationale: Precipitating factors for developing delirium include infection, a fracture or trauma, and a history of hypoglycemia. Excessive sleep and moderate alcohol use are not precipitating factors for delirium. Next Question
The spouse of a client diagnosed with delirium tells the nurse, "I'm not sure what caused this, as my spouse has never had any mental issues before." Which potential cause should the nurse include in the response to the client's spouse? (Select all that apply.)
Answer: infection, sleep deprivation, drug or alcohol use Rationale: Causes of delirium include sleep deprivation, infection, and drug or alcohol use or withdrawal. Irritable bowel disease and thyroid disease have not been shown to cause delirium. Next Question
The nurse is developing a plan of care for a client who is diagnosed with delirium. Which nursing goal should the nurse include? (Select all that apply.)
Answer: preventing further cognitive impairment, providing a safe, therapeutic environment, promoting resolution for the condition causing the delirium Rationale: Nursing interventions for the client with confusion and delirium revolve around providing a therapeutic environment for the client to feel safe in, preventing further cognitive impairment, and promoting resolution of whatever condition is causing the delirium. It is not possible to restore the client to better-than-previous functioning. The aim of treatment for delirium is not to treat all mental health issues, but to deal with the confusion and underlying condition causing the delirium.
Which nursing intervention is most appropriate for the nurse to implement for a client with delirium? (Select all that apply.)
Answer: providing adequate pain management, using calendars and clocks to reorient patient, assign the same nurse to care for the patient each day Rationale: Appropriate nursing interventions for the client diagnosed with delirium include using calendars and clocks to reorient the client. Providing adequate pain management addresses an underlying cause of delirium. Assigning the same nurse to care for the client each day provides consistency and safety. Lights should be kept at an appropriate level during day and night to ensure proper sleep and rest times. Loved ones should be encouraged to visit the client to provide familiarity and a feeling of safety.
The nurse is teaching the family of a client diagnosed with delirium how to maintain safety in the home. Which information is most important for the nurse to include?
Answer: side effects of medications that might cause cognitive changes Rationale: It is important for the nurse to carefully explain to the client's family any side effects of medications that might cause cognitive changes and what to do if these occur. Lab tests, diet restrictions, and activity restrictions may not be ordered for the client. If they are, they are not as necessary to maintain safety in the home as is preparing the family for coping with confusion. Next Question
Which condition should the nurse expect the healthcare provider to evaluate for an older adult client who is diagnosed with delirium of unknown cause? (Select all that apply.)
Answer: stroke, dehydration, UTI, new prescription medication Rationale: Intracranial events (like stroke or bleeding), infections (respiratory or urinary tract), and dehydration often manifest themselves as delirium in older adult clients. Prescription medications such as hypnotics/sedatives, anxiolytics, antidepressants, anti-Parkinson drugs, anticonvulsants, or antispasmodics also increase the risk of delirium. UTIs, if not diagnosed and treated promptly, can lead to infection and sepsis, which cause delirium. Celiac disease is an autoimmune disease of gluten sensitivity and is not associated with manifestations of delirium.
The family of a client diagnosed with delirium asks what they can expect. Which symptom should the nurse include in the response to the family? (Select all that apply.)
Answer: sudden loss of both long term and short term memory, might look physically unwell; acute onset of irrational and repetitive behaviors, fluctuations in the intensity and level of consciousness, from drowsy to near unconsciousness Rationale: Clients with delirium have fluctuations in the intensity and level of consciousness, from drowsiness to near unconsciousness. They might have both long-term and short-term memory problems, look physically unwell, and have acute onset of irrational and repetitive behaviors. A client experiencing angina or myocardial infarction would experience chest pain that radiates to the left arm. A client diagnosed with bipolar disorder may exhibit manic behavior with flight of ideas.
The parent of an adolescent asks the nurse, "I've heard that teenagers can be at risk for delirium. Can you tell me why?" Which cause should the nurse include in the response? (Select all that apply.)
Answer: tendency for risk taking behaviors, drug and substance abuse and withdrawal, risk of head injuries from playing contact sports Rationale: Adolescents may be at increased risk for the development of delirium because they engage in contact sports with an increased risk of head trauma. They also have a tendency to engage in risk-taking behaviors and often engage in drug or substance abuse. Adolescents have increased ability to compensate for physiologic alterations that precipitate delirium. They also have a tendency to engage in impulsive behavior, not carefully thinking about results of behavior. Next Question
The nurse is caring for a client diagnosed with delirium. Which outcome should lead the nurse to determine that treatment is successful? (Select all that apply.)
Answer: the client remains free of injury, the client maintains adequate nutrition, the client returns to optimal level of functioning, if possible Rationale: One expected outcome for delirium is that the client will return to the level of functioning she had before the onset of the delirium. The client should remain free of injury and maintain adequate nutrition. Verbalizing feelings of being able to cope with the disease and preparing advanced future planning for progressive disease stages are expected outcomes for clients with Alzheimer disease, who are not expected to return to an optimal level of functioning. Next Question
Which assessment finding for a client with delirium should lead the nurse to determine that treatment was successful?
Answer: the patient communicates with the nurse on a variety of topics. Rationale: As delirium resolves, the client is able to communicate clearly and transitions logically between topics. The client should be able to perform ADLs without assistance, should remain free of injury (and not fall out of bed), and should be oriented to person, place, and time. Next Question
The nurse is planning care for a client who is diagnosed with delirium. Which goal is most appropriate for the nurse to assign to this client?
Answer: the patient will have adequate sleep and rest Rationale: Clients with delirium often experience a disturbed sleep pattern. As their confusion fades, natural, normal sleep becomes more of a reality. An appropriate goal for the client with delirium is to be able to perform ADLs without assistance. Suicidal thoughts are not normally a part of delirium. It is not expected that the client will express understanding of the disease process. Next Question
The nurse is caring for a client with delirium in the ICU. Which finding should the nurse consider as a contributing factor? (Select all that apply.)
Answer: unrelieved pain, awakened for frequent assessments and treatment, admitted after a MVC with blood alcohol level 0.25% Rationale: Recognizing the cause of delirium in a client in the ICU will allow the nurse to implement interventions to alleviate or reduce delirium. Prolonged sleep deprivation and sensory overload can precipitate delirium, as can untreated pain, poor pain management, and withdrawal from alcohol or drugs. Cerebral atherosclerosis and atrophy of the hippocampus are associated with dementias and cannot be modified by nursing interventions. Next Question
The nurse is caring for an older adult client who progressively develops symptoms of delirium. Which collaborative intervention should the nurse expect to implement first?
Answer: urine culture and sensitivity Rationale: In older adult clients, delirium often is the most common manifestation of other conditions, most notably of urinary tract infections. Getting a urine culture and sensitivity will help determine if that is the cause of the client's symptoms. Restraints are never the first option. Abdominal x-rays are done to visualize abdominal structures, and ECGs are done to examine cardiac rhythms. Neither factors into the development of delirium. Next Question
The nurse is caring for a client who is diagnosed with delirium. The client's spouse is upset and tells the nurse, "I don't know how I am going to be able to care for my spouse, who can no longer think clearly." How should the nurse respond?
Answers: "it's important for you to know that, generally, delirium is reversible" Rationale: Delirium generally signals the presence of a reversible but potentially life-threatening condition. Early detection and management of delirium may mitigate the consequences of the condition. If treated, delirium does not deteriorate, and it is more prevalent in older rather than younger clients. Telling family members that they will be fine gives false reassurance and dismisses their concerns.
