Difficulty: Medium
Average Score: 66%
Simulated
Passage / Scenario
ProviderÔÇÖs Note0230:
Client diagnosis: Delirium secondary to a urinary tract infection and dehydration.
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 assessment, 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 their room, client voided 250 mL of dark yellow, cloudy urine.
Laboratory Results
0230:
Serum toxicology screen:
Alcohol 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
The nurse has reviewed the nursesÔÇÖ notes, providerÔÇÖs note, and laboratory results at 0230.Exhibits:For each clientÔÇÖs finding, specify if the finding is consistent with delirium or AlzheimerÔÇÖs disease. Each finding may support more than one disease process or none at all. There must be at least one selection in every column. There does not need to be a selection in every row.
Rationale
Correct Answer:
Rationale:
- Sudden onset of confusion is more indicative of delirium due to its acute and fluctuating nature.
- Hallucinations can be seen in both delirium and Alzheimer's but are more common in delirium.
- Agitation is a common symptom in delirium and can also occur in Alzheimer's.
- Current medical diagnosis should also be checked to understand the overall clinical picture.
- Therefore, the correct answer selects all options as each finding can potentially support either delirium or Alzheimer's disease.
Rationale:
- Sudden onset of confusion is more indicative of delirium due to its acute and fluctuating nature.
- Hallucinations can be seen in both delirium and Alzheimer's but are more common in delirium.
- Agitation is a common symptom in delirium and can also occur in Alzheimer's.
- Current medical diagnosis should also be checked to understand the overall clinical picture.
- Therefore, the correct answer selects all options as each finding can potentially support either delirium or Alzheimer's disease.