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 highest priority in managing acute delirium is ensuring patient safety and preventing 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.
- Reducing stimuli helps to decrease perceptual disturbances like illusions and hallucinations, which are common in delirium and can be terrifying for the patient.
Why Other Options Were Wrong
- Option A: A client experiencing acute delirium has impaired attention and memory, making them unable to learn or follow instructions for Activities of Daily Living (ADLs).
- Option B: While maintaining nutrition and hydration is important, it is not the most immediate priority. The risk of injury from agitation or confusion is a more acute threat than the consequences of a missed meal.
- Option C: Although reorientation is a core treatment for delirium, it is not the first priority. Its effectiveness is significantly reduced if the client is agitated or overstimulated by the environment. Safety and environmental control must come first.
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 delirious patient should be to assess for and mitigate environmental hazards and stimuli, such as a loud TV, bright lights, or clutter.
- Failure to prioritize environmental safety can lead to falls, self-harm (e.g., pulling out IV lines), and the need for physical or chemical restraints, which can worsen delirium.
- What if? The client was also showing signs of dehydration (e.g., dry mucous membranes, poor skin turgor). While environmental control remains the immediate priority for safety, identifying and initiating treatment for the underlying physiological cause (dehydration) would become an equally high and concurrent priority.
How to Approach the Question
- First, identify the keywords in the question: 'first priority' and 'delirium'.
- Recall that delirium is an acute medical emergency characterized by confusion, inattention, and agitation. The patient's safety is at immediate risk.
- Apply the nursing principle of 'Safety First'. Before addressing cognitive symptoms or routine needs, you must ensure the patient is safe in their environment.
- Evaluate the options through the lens of safety. Providing a calm, non-stimulating environment directly reduces the risk of agitation and injury.
- Compare this to other actions. Reorientation is a cognitive intervention, while assisting with eating and ADLs are routine care. These are important but are secondary to establishing a safe environment.
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
- 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 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.
More Organic Brain Disorders Questions
- A patient admitted in a ward with the diagnosis of delirium. In first 24 to 48 hours what nurse plan according to priority:
- Which of the following are the causes of delirium?
- What is the most common cause of delirium in older adults?
- Most common cause of delirium in elderly person?
- An example of acute organic mental disorder?
- What is "sun drowning"?
- Which of the following features is present only in Dementia when compared with Delirium?
- A nurse enters the room of a patient with a cognitive impairment disorder and asks what day of the week it is; what the date, month and year are; and…
- A 75-year-old patient has dementia of the Alzheimer's type and confabulates. A nurse should understand that this patient?
- A 54-year-old male patient admitted with memory impairment. His Mini-Mental State Examination (MMSE) score ranges from 10 - 18 points, which indicate…
More AIIMS Delhi NO - 2018 Questions
- Another tentative diagnosis made for the client is Wernicke's Encephalopathy. If the client has this, the nurse anticipates that the first physician'…
- A 35-year-old man was in an automobile accident with an admitting diagnosis of a head injury. He has a Glasgow Coma Scale score of 4. Upon MRI and CT…
- A 28-year-old male client is admitted to the hospital for a suspected brain tumor. While assessing this client, the nurse would keep in mind that the…
- Following admission to the hospital, a diagnosis of increasing intracranial pressure was made. The nursing intervention appropriate in the care of th…
- The nurse has orders to administer phenytoin (Dilantin) 100 mg IV as an anticoagulant. The priority action while administering this drug is to:
- The client is to take lithium regularly after she is discharged from the hospital. The nursing care plan includes discharge planning. The most import…
- A patient is taking a proper diet as prescribed for bulimia nervosa, but the patient's weight is not gaining. Which nursing action is appropriate?
- Identify the size of the cannula shown here?& x20;
- Identify the following image? & x20;
- Identify the instrument below?& x20;