Patient Data

Exhibits

Data is evaluated to determine possible condition and appropriate interventions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Rationale for Correct Answers:

• Delirium: The client shows sudden confusion, difficulty remembering events, disorientation to time and place, and inconsistent attention span. These symptoms developed acutely after surgery, indicating delirium rather than dementia or depression, which have slower onset and different characteristics.
• Institute fall precautions: Delirium increases fall risk due to confusion, impaired judgment, and unawareness of physical limitations. This client has already shown poor safety awareness (e.g., forgetting what a call light is), making fall precautions essential.
• Reorient to environment: Repeated verbal reminders of place, time, and situation help reduce confusion and anxiety in delirious patients. The client is unsure why she is hospitalized and forgets instructions, making reorientation a key nursing strategy.
• Nutritional intake/intake and output: The client is eating poorly and has signs of dehydration (dry mucosa, tenting). Monitoring intake and output supports correction of fluid/electrolyte imbalances, which can worsen delirium if untreated.
• Drug therapy: Older adults are more sensitive to medication side effects, especially those that affect cognition. Monitoring the effects of prescribed drugs is crucial since inappropriate or excessive medication can contribute to or worsen delirium.

Rationale for Incorrect Answers:

• Dementia: Dementia presents as a chronic, progressive decline in cognitive function. The client’s confusion is recent, fluctuates, and appeared postoperatively, which is not consistent with the gradual, irreversible decline typical of dementia.
• Depression: While older adults may have decreased appetite or low energy due to depression, the client’s acute confusion, memory loss, and inability to perform familiar tasks point more strongly toward delirium rather than mood-related impairment.
• Remove all objects that could cause harm: While this may be helpful in some situations, the client is not displaying aggressive behavior or intentional self-harm. Delirium management focuses more on supervision, reorientation, and safety support.
• Family involvement: While helpful in long-term care, family involvement is not the most immediate or measurable parameter in evaluating acute delirium. The priority is physiologic stabilization and cognitive assessment.
• Intracranial pressure: There is no evidence of increased ICP (e.g., no severe headache, vomiting, pupil changes). Delirium is more likely due to metabolic or environmental factors, not intracranial pressure elevation in this context.