AIIMS Delhi NO - 2018
Mental Health Nursing
Medium
A nurse is caring for a client with a history of delirium in the psychiatry department. Which is the first priority?
Appeared in: AIIMS Delhi NO - 2018
Explanation
- The primary goal in managing acute delirium is to ensure patient safety and prevent harm.
- Providing a calm, quiet, and non-stimulating environment is the foundational step to reduce agitation, prevent sensory overload, and minimize the risk of injury.
- This environmental control creates a therapeutic setting that is a prerequisite for other interventions, such as reorientation, to be effective.
- This action directly addresses the hyper-reactivity to stimuli and perceptual disturbances that characterize delirium.
Why Other Options Were Wrong
- Option A: A client with delirium has impaired attention and memory, making them unable to follow instructions for ADLs. This is a long-term goal for after the delirium resolves, not an acute priority.
- Option B: While nutrition is important, immediate safety and managing acute agitation take precedence over routine physiological needs. The risk of falls or self-harm is more immediate than the risk of malnutrition.
- Option C: Although reorientation is a key treatment for the cognitive symptoms of delirium, its effectiveness is limited if the client is overstimulated by the environment. Creating a calm space is the prerequisite for this intervention to be successful.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Prioritization of nursing interventions for a client with delirium to guide bedside assessment, documentation, and the next nursing action.
- A nurse's first action upon entering the room of a potentially delirious patient should be to assess the environment for safety risks and sources of overstimulation (e.g., loud TV, bright lights, multiple visitors).
- Failure to prioritize environmental safety can lead to falls, inadvertent removal of IV lines, and physical aggression, posing a risk to both the patient and staff.
- What if? The client was also showing signs of severe dehydration (e.g., hypotension, tachycardia). While environmental control remains the immediate priority for safety, initiating IV fluids to correct the underlying physiological cause would become an equally high and concurrent priority.
How to Approach the Question
- First, identify the key phrase in the question: 'first priority'. This signals that you must rank the nursing actions in order of importance.
- Recognize that the client's condition is delirium, an acute medical emergency characterized by confusion, fluctuating consciousness, and potential agitation.
- Apply the nursing principle of 'safety first.' In any situation involving altered mental status, ensuring the client is safe from harm is the paramount initial action.
- Evaluate the options based on the safety principle. Providing a calm and non-stimulating environment directly addresses safety by reducing triggers for agitation and preventing injury.
- Contrast this with other options. Reorientation is a cognitive intervention, while ADL instruction and eating assistance are secondary to immediate safety. The environment must be managed first to allow other interventions to succeed.
Concept Tested & Keywords
- Concept Tested: Prioritization of nursing interventions for a client with delirium.
- Stem keywords: delirium, psychiatry, first priority
- Lead-in keywords: first priority
- Clinical cues: The diagnosis of delirium is the key cue, as it signals an acute medical emergency characterized by confusion and agitation, making safety the top concern.
- Negative lead-in flag: false
Question ID
Q-25gB40GQQL6_H7E0A_Le
Reference Book
E6 Guide to Mental Health & PSYCHIATRIC NURSING R Sreevani— Part 2 (pp 290-564 of 579) p. 68-70
E6 Medicine Harrison 22e Part 1 p. 226-228
E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) p. 13838-13840
Practise the full AIIMS Delhi NO - 2018
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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