A nurse is assessing an older adult client who has been admitted to the hospital with pneumonia.

The nurse suspects that the client has developed delirium based on which of the following findings?

The correct answer is C. “I know this is scary for you.

I am here to help you.” This statement shows empathy and reassurance to the client who has delirium and is experiencing hallucinations.

The nurse should also use a calm and soothing voice, maintain eye contact, and orient the client to reality.

Choice A is wrong because it is dismissive and invalidating of the client’s experience.

It can also increase the client’s anxiety and agitation.

Choice B is wrong because it can encourage the client to focus on the hallucinations and reinforce their delusions.

It can also make the client more fearful and confused.

Choice D is wrong because it is unrealistic and unhelpful.

The client cannot ignore the hallucinations that are distressing to them.

They also need support and intervention to address the underlying cause of delirium.

Delirium is a disturbance of consciousness and a change in cognition that develop rapidly over a short period.

It can be caused by various factors such as medical conditions, medications, substance use or withdrawal, infections, dehydration, pain, or emotional stress.

Delirium can manifest as hyperactive, hypoactive, or mixed type, with different levels of arousal, psychomotor activity, and mood.

Nursing interventions for delirium include assessing the patient’s cognitive and functional ability, using non-pharmacological methods such as multi-component interventions, family involvement, and light therapy, and recognizing delirium as a medical emergency that requires frequent monitoring and advocacy.

General measures to support cerebral function, such as hydration, nourishment, and oxygen, are also important.

Physical restraints are used only as a last resort.

For more information on delirium nursing diagnosis and care management, please refer to these sources:.

The correct answer is B.

The client has a decreased level of consciousness and is difficult to arouse.

This is a sign of delirium, which is a fast-developing type of confusion that affects attention and awareness.

Delirium is often caused by a combination of factors, such as infection, medication, surgery or dehydration.

Delirium is more common in older adults, especially those with dementia or other chronic conditions.

Choice A is wrong because difficulty remembering recent events and conversations is more likely a sign of dementia, which is a slow and progressive decline in memory and other thinking skills.

Dementia can also increase the risk of delirium, but it is not the same condition.

Choice C is wrong because having a history of Alzheimer’s disease and taking donepezil daily does not necessarily mean that the client has delirium.

Alzheimer’s disease is a type of dementia that affects memory, language and behavior.

Donepezil is a medication that can help improve cognitive function in some people with Alzheimer’s disease.

However, neither Alzheimer’s disease nor donepezil can cause delirium by themselves.

Choice D is wrong because having a normal blood pressure and pulse rate does not rule out delirium.

Delirium can affect people with normal vital signs, as well as those with abnormal ones.

Delirium is more related to brain function than to cardiovascular function.

Normal ranges for blood pressure are less than 120/80 mmHg for systolic/diastolic pressure, and for pulse rate are 60 to 100 beats per minute.

However, these ranges may vary depending on age, health status and other factors.