Which of the following patients is MOST likely to be experiencing delirium? A. A 94 year old female who answered "September 5" instead of "September 15" when asked what day it is B. A 34 year old male diagnosed with a right femur fracture who is talking in his sleep after receiving 1mg of Dilaudid ...
NUR 425 Practice Questions and Correct
Answers
Which of the following patients is MOST likely to be experiencing delirium?
A. A 94 year old female who answered "September 5" instead of "September 15" when
asked what day it is
B. A 34 year old male diagnosed with a right femur fracture who is talking in his sleep
after receiving 1mg of Dilaudid IV
C. An 81 year old male who was alert and oriented x4 yesterday, but appears upset with
you today . He is convinced you are the city police and that you are trying to take him
back to jail.
D. A 79 year old female admitted with a GI bleed who you cared for yesterday that does
not remember your name. She also thought it was 8pm instead of 8am before you
brought in her breakfast tray. ✅C. An 81 year old male who was alert and oriented x4
yesterday, but appears upset with you today . He is convinced you are the city police
and that you are trying to take him back to jail.
Which of the following could be appropriate nursing interventions for the patient
experiencing delirium? (Select all that apply)
A. Frequently orient the patient
B. Monitor for potential risk factors such as dehydration, constipation, or pain
C. Ensure the patient always has an indwelling urinary catheter to reduce incontinence
D. Ensure the patient has any devices in place such as glasses or hearing aids
E. Wake the patient up frequently during the night to remind the patient of where he/she
is
F. Provide the patient with puzzles, washcloths to fold, or a coloring book ✅A.
Frequently orient the patient
B. Monitor for potential risk factors such as dehydration, constipation, or pain
D. Ensure the patient has any devices in place such as glasses or hearing aids
F. Provide the patient with puzzles, washcloths to fold, or a coloring book
Which of the following is an appropriate assessment tool for delirium in the ICU?
A. Ramsey Scale
B. RAAS
C. CPOT
D. CAM-ICU ✅D. CAM-ICU
Which of the following is true about pharmacologic management of delirium?
A. Most sedatives are not associated with delirium in ICU patients
B. Benzodiasepines and narcotics may actually worsen a patient's cognition rather than
treat delirium
C. One of the risk factors of Haloperidol is a shortened QT interval
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