NCLEX-PN® ExaminationPsychosocial IntegrityHard
A practical nurse is caring for an older adult client who is exhibiting sudden confusion, disorientation, and fluctuating levels of consciousness. The client has a history of multiple comorbidities. The nurse suspects delirium. Which of the following is the priority nursing intervention?
- AProvide a quiet, dimly lit environment.
- BAdminister a PRN sedative to reduce agitation.
- CAssess for underlying physiological causes.
- DOrient the client to person, place, and time frequently.
Show answer & explanationAnswer & explanation
Correct answer: C. Assess for underlying physiological causes.
Delirium is often caused by an underlying acute medical condition (e.g., infection, dehydration, medication side effects). Identifying and treating the root cause is the priority intervention to resolve the delirium and prevent further complications. Without addressing the cause, other interventions will likely be ineffective.
Why the other options are wrong
- A. A calm environment is helpful for managing symptoms but does not address the underlying cause of the delirium.
- B. Sedatives can worsen delirium in older adults and should only be used as a last resort if safety is severely compromised, and after the cause is being addressed.
- D. Orientation is a supportive intervention but will not resolve the underlying cause of delirium.
Delirium: Priority Intervention
The priority intervention for a client with suspected delirium is to identify and treat the underlying physiological cause, as delirium is an acute, reversible confusional state.
- Common causes: infection, dehydration, polypharmacy, electrolyte imbalance.
- Rapid onset, fluctuating course.
- Distinguished from dementia by acute onset and reversibility.
Memory trick: Find the Root, Fix the Problem.