AIIMS Delhi NO- 2019
Mental Health Nursing
Medium
A patient admitted in a ward with the diagnosis of delirium. In first 24 to 48 hours what nurse plan according to priority:
Appeared in: AIIMS Delhi NO- 2019
Explanation
- The highest priority for a patient with delirium is ensuring their safety, which is directly addressed by managing their acute confusion.
- Frequent reorientation to person, place, and time is a fundamental nursing intervention that helps to reduce the anxiety, fear, and agitation associated with delirium.
- By anchoring the patient to reality, the nurse can decrease the risk of the patient attempting unsafe actions, such as getting out of bed unassisted or removing essential medical devices.
- This intervention provides a sense of security and is the foundation upon which other supportive care measures are built.
Why Other Options Were Wrong
- Option B: While important, managing bladder and bowel function is not the most immediate priority. Issues like urinary retention or constipation can worsen delirium, but they do not pose the same immediate safety threat as acute confusion and disorientation.
- Option C: Restoring the sleep-wake cycle is a critical component of delirium management, as its disruption is a core feature. However, it is an intervention managed over a 24-hour period through environmental controls and promoting daytime activity. It is not a single, first-priority action compared to the moment-to-moment need for reorientation to ensure safety.
- Option D: Poor nutrition and dehydration are common causes and consequences of delirium. While addressing nutritional status is vital for recovery, it is generally not as immediately life-threatening as the safety risks posed by acute confusion.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Prioritization of nursing care for a patient with delirium to guide bedside assessment, documentation, and the next nursing action.
- Delirium is a medical emergency linked to increased morbidity, mortality, and long-term cognitive decline. Nurses are often the first to detect changes in a patient's mental status.
- Nurses should use a validated screening tool, such as the Confusion Assessment Method (CAM), to systematically assess for delirium in at-risk patients.
- What if? If the patient was experiencing hyperactive delirium with severe agitation and was a danger to themselves or staff, the priority would escalate from simple reorientation to ensuring immediate physical safety. This could involve one-to-one supervision (a sitter) and, as a last resort, considering chemical or physical restraints while continuing de-escalation and reorientation efforts.
How to Approach the Question
- First, identify the question type: It's a clinical scenario asking for the priority nursing action.
- Next, analyze the patient's diagnosis: Delirium. Recall that delirium is an acute confusional state.
- Apply a prioritization framework. For confused patients, safety is always the number one priority. Think about which action most directly promotes safety.
- Evaluate the options: A) Reorientation directly addresses confusion to improve safety. B) Bowel/bladder care is important but less immediate. C) Sleep cycle is a 24-hour goal, not the first action. D) Nutrition is supportive care, not an immediate safety measure.
- Conclude that reorientation is the most direct and immediate intervention to manage the core problem (confusion) and ensure safety.
Concept Tested & Keywords
- Concept Tested: Prioritization of nursing care for a patient with delirium.
- Stem keywords: delirium, first 24 to 48 hours, priority, nursing plan
- Lead-in keywords: what nurse plan according to priority
- Clinical cues: Diagnosis of delirium implies an acute confusional state, making safety the primary concern.
Question ID
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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- 2019
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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