The correct answer is B.

The client has a decreased level of consciousness and is difficult to arouse.

This is a sign of delirium, which is a fast-developing type of confusion that affects attention and awareness.

Delirium is often caused by a combination of factors, such as infection, medication, surgery or dehydration.

Delirium is more common in older adults, especially those with dementia or other chronic conditions.

Choice A is wrong because difficulty remembering recent events and conversations is more likely a sign of dementia, which is a slow and progressive decline in memory and other thinking skills.

Dementia can also increase the risk of delirium, but it is not the same condition.

Choice C is wrong because having a history of Alzheimer’s disease and taking donepezil daily does not necessarily mean that the client has delirium.

Alzheimer’s disease is a type of dementia that affects memory, language and behavior.

Donepezil is a medication that can help improve cognitive function in some people with Alzheimer’s disease.

However, neither Alzheimer’s disease nor donepezil can cause delirium by themselves.

Choice D is wrong because having a normal blood pressure and pulse rate does not rule out delirium.

Delirium can affect people with normal vital signs, as well as those with abnormal ones.

Delirium is more related to brain function than to cardiovascular function.

Normal ranges for blood pressure are less than 120/80 mmHg for systolic/diastolic pressure, and for pulse rate are 60 to 100 beats per minute.

However, these ranges may vary depending on age, health status and other factors.

The correct answer isA, C, and E.

Here is why:.

A. Administer antibiotics as prescribed.This is correct because antibiotics are the main treatment for urinary tract infections (UTIs), which can cause delirium in older adults.Antibiotics can help clear the infection and reduce the inflammation that affects the brain function.

B. Restrict fluids to prevent fluid overload.This is incorrect because restricting fluids can worsen dehydration, which is a risk factor for delirium.Fluids help flush out bacteria from the urinary tract and prevent constipation, which can also contribute to delirium.Older adults should drink enough fluids to keep their urine clear or pale yellow.

C. Provide frequent reorientation and reassurance.This is correct because delirium causes confusion, anxiety, and reduced awareness of surroundings.Reorientation and reassurance can help the person feel more secure and calm, and reduce the risk of agitation or wandering.Reorientation can include reminding the person of their name, date, time, and place, and using familiar objects or pictures.

D. Use restraints to prevent injury or wandering.This is incorrect because restraints can increase the risk of delirium by causing physical discomfort, emotional distress, and sensory deprivation.Restraints can also lead to complications such as pressure ulcers, infections, or injuries from struggling.Restraints should only be used as a last resort when other measures have failed to ensure safety.

E. Encourage family members to stay with the client.This is correct because family members can provide emotional support, comfort, and familiarity to the person with delirium.Family members can also help with communication, monitoring, and care coordination.Family involvement can reduce the duration and severity of delirium.

References:.

:Delirium - Symptoms and causes - Mayo Clinic.

:Urinary Tract Infection Induced Delirium in Elderly Patients: A Systematic Review - PMC Journal List.

:Urinary tract infections and dementia | Alzheimer’s Society.

:What is Delirium and its causes and related conditions?.

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:.

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 B.

Delirium is a reversible condition that can be cured with proper treatment.

Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of one’s surroundings.It usually comes on fast and can be caused by various factors, such as infection, medication, surgery, or alcohol or drug use or withdrawal.Delirium can often be prevented and treated by addressing the underlying causes and providing supportive care.

Choice A is wrong because delirium is not a chronic condition that causes progressive cognitive decline.

That description fits dementia, which is different from delirium.Dementia is a gradual loss of memory and other thinking skills due to damage or loss of brain cells.

Choice C is wrong because delirium is not a normal part of aging that does not require any intervention.

Delirium is a medical emergency that needs prompt attention and treatment.Delirium can have serious consequences, such as functional decline, institutionalization, and death.

Choice D is wrong because delirium is not a genetic condition that runs in families.Delirium is not inherited, but rather triggered by environmental factors or medical conditions that affect the brain.

Normal ranges for mental status assessment in older adults are based on standardized tools, such as the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA).

These tools measure various aspects of cognition, such as orientation, memory, attention, language, and executive function.

The MMSE has a maximum score of 30, and the MoCA has a maximum score of 26.

A score below 24 on the MMSE or below 18 on the MoCA may indicate cognitive impairment.

However, these tools are not diagnostic of delirium or dementia, and should be interpreted in the context of the patient’s history and clinical presentation.