In a medical-surgical unit, the nurse is monitoring several patients. Which patient does the nurse identify as being at the highest risk for developing delirium?

A 32-year-old patient with gastroenteritis.

A 60-year-old patient with type II diabetes, 2 months post bilateral above-knee amputations.

A 55-year-old patient with coronary artery disease, 4 days post coronary bypass surgery.

An 80-year-old patient with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis.

Answer and Explanation

The Correct Answer is D

An 80-year-old patient with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis is at the highest risk for developing delirium. Multiple factors such as advanced age, severe illness, and multiple comorbidities increase the risk of delirium.

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Correct Answer is C

Explanation

Choice A rationale
Monitoring mental status is important, but it is not the priority nursing action in this situation. The individual has been found after being missing for 48 hours and the immediate concern should be their physical well-being.
Choice B rationale
Encouraging the individual to recall recent events may be part of the assessment process, but it is not the priority nursing action. The individual’s physical health could be at risk after being outside for an extended period, and this should be addressed first.
Choice C rationale
Assessing vital signs is the priority nursing action. The individual has been found after being missing for 48 hours, potentially exposed to harsh weather conditions and without access to food or water. It is crucial to assess their physical state as they may be dehydrated, hypothermic, or have other immediate health concerns.
Choice D rationale
Contacting family members is important for providing information and support, but it is not the priority nursing action. The first concern should be to assess and stabilize the individual’s physical condition.

A. True B. False.

Correct Answer is A

Explanation

Lability is characterized by rapid, often unpredictable changes in emotions.

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In a medical-surgical unit, the nurse is monitoring several patients. Which patient does the nurse identify as being at the highest risk for developing delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

True or False: Lability is characterized by a rapid change in emotions.

Correct Answer is A

Explanation

A patient with a history of suicidal ideation is under observation. When is the patient at the highest risk for self-harm?

True or False: The management of delirium is dependent on its cause, with the primary focus being to address the root cause.

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