A nurse is planning care for an older adult client who is at risk for developing delirium due to a urinary tract infection.

Which of the following interventions should the nurse include in the plan?

(Select all that apply.).

The correct answer is C.

“I remember that you are my nurse and your name is Lisa.” This statement indicates an improvement in the condition of delirium, which is a temporary mental state characterized by confusion, anxiety, incoherent speech, and hallucinations.

Delirium can be caused by various factors, such as fever, infection, medication, surgery, or alcohol or drug use or withdrawal.

Delirium can have different types: hyperactive, hypoactive, or mixed.

Delirium can be distinguished from dementia by its acute and fluctuating onset, reduced awareness of surroundings, and poor thinking skills.

Choice A is wrong because “I don’t know where I am or what day it is.” indicates a lack of orientation to time and place, which is a sign of delirium.

Choice B is wrong because “I feel so sleepy all the time.

I just want to rest.” indicates a hypoactive type of delirium, which is characterized by reduced activity, sluggishness, and drowsiness.

Choice D is wrong because “I still hear voices sometimes, but they are not as loud.” indicates a presence of hallucinations, which is a symptom of delirium.

Normal ranges for cognitive function in older adults depend on various factors, such as age, education, culture, and health status.

However, some general indicators of normal cognition include being able to recall recent events, recognize familiar people and places, communicate clearly and coherently, and perform daily activities independently.

References:.

• Delirium - Symptoms and causes - Mayo Clinic.

• Delirium in elderly adults: diagnosis, prevention and treatment.

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:.