What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
Avoidance of physical contact
Application of wrist and ankle restraints
Careful observation and supervision
High level of sensory input
The Correct Answer is C
A. Avoidance of physical contact is not the priority intervention for a patient with delirium. While you may want to be gentle and avoid unnecessary contact, the priority is to ensure the patient's safety and provide support in a way that helps prevent injury, confusion, or further agitation.
B. Application of wrist and ankle restraints is not recommended unless absolutely necessary for patient safety (such as if the patient is at risk of harming themselves or others). Restraints should be a last resort and only used when all other interventions have failed.
C. Careful observation and supervision is the priority nursing intervention for a patient with delirium. Due to fluctuating levels of consciousness and altered perception, the patient is at risk for injury (e.g., falling, wandering). Close observation helps ensure the patient's safety and provides an opportunity to intervene if the condition worsens.
D. High level of sensory input is generally not recommended for patients with delirium, as it may increase confusion and agitation. Instead, providing a calm, quiet environment with minimal distractions is typically preferred.
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Related Questions
Correct Answer is B
Explanation
A. Prevent breakdown of acetylcholinesterase by inhibiting the action of acetylcholine is incorrect because the mechanism of Donepezil (Aricept) involves inhibiting acetylcholinesterase, not acetylcholine itself. The goal is to increase the levels of acetylcholine in the brain by preventing its breakdown.
B. Prevent breakdown of acetylcholine by inhibiting the action of acetylcholinesterase is the correct mechanism. Donepezil is a cholinesterase inhibitor. By inhibiting acetylcholinesterase (the enzyme that breaks down acetylcholine), Donepezil increases the amount of acetylcholine available to stimulate receptors in the brain, which helps improve symptoms of Alzheimer's disease.
C. Promote breakdown of acetylcholine by inhibiting the action of acetylcholinesterase is incorrect because Donepezil prevents the breakdown of acetylcholine, not promotes it.
D. Promote breakdown of acetylcholinesterase by inhibiting the action of acetylcholine is also incorrect. The purpose of Donepezil is to prevent the breakdown of acetylcholine, not to break down acetylcholinesterase itself.
Correct Answer is C
Explanation
A. Delirium is an acute, often sudden onset of confusion and altered mental status, usually caused by an underlying medical condition or medication. It tends to fluctuate and is typically reversible — not consistent with the progressive and long-term decline described.
B. Amnesia refers specifically to memory loss, which can be caused by trauma, disease, or psychological factors, but it does not encompass the broader cognitive decline (such as impaired judgment, language, and executive function) seen in dementia.
C. Dementia is characterized by a gradual and progressive decline in memory, thinking, and reasoning skills over time. The two-year progression described in the question is typical of dementia, especially in older adults.
D. Parkinson’s disease is a neurodegenerative disorder primarily affecting movement.While it can be associated with dementia in later stages, the primary symptoms early on are related to motor function (e.g., tremors, rigidity), not memory and cognition.
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