Difficulty: Medium
Average Score: 76%
Simulated
Passage / Scenario
ProviderÔÇÖs Note0230:
Client diagnosis: delirium secondary to a urinary tract infection and dehydration.
Laboratory Results
0230:
Serum toxicology screen:
Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Vital Signs
0200:
Temperature 38.6┬░C (101.5┬░F)
Heart rate 104/min
Respiratory rate 18/min
Blood pressure 158/96 mm Hg
Oxygen saturation 98% on room air
NursesÔÇÖ Notes
0205:
Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified.
Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular.
During data collection, client states, ÔÇ£Can you ask that person to leave my room?ÔÇØ Client is pointing to an empty chair.
0230:
ClientÔÇÖs adult child arrived to the ED and went to clientÔÇÖs room. Client identified family member. Client is pacing and agitated, and states, ÔÇ£I donÔÇÖt understand why I am here.ÔÇØ Adult child asks nurse to talk outside of room and states, ÔÇ£I donÔÇÖt know why they are so confused. They are not normally like this.ÔÇØ Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to room, client voided 250 mL of dark yellow, cloudy urine.
The nurse has reviewed the nursesÔÇÖ notes, providerÔÇÖs note, and laboratory results at 0230. Exhibits For each client finding, click to specify if the finding is consistent with delirium or AlzheimerÔÇÖs disease. Each finding may support more than one disease process.
Rationale
Agitation (A) and hallucinations (D) occur in both; diagnosis (B) of delirium and sudden confusion (C) are delirium-specific, unlike AlzheimerÔÇÖs gradual onset.