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 in managing delirium is ensuring patient safety, as the condition involves acute confusion, disorientation, and potential agitation.
- Frequent reorientation to person, place, and time is a fundamental, non-pharmacological intervention that directly addresses the patient's confusion.
- By reducing confusion and anxiety, reorientation helps to prevent unsafe behaviors such as falls, pulling out medical devices, or attempting to leave.
- This intervention establishes a therapeutic rapport and a sense of security, which is foundational for all other aspects of care.
Why Other Options Were Wrong
- Option B: While maintaining bladder and bowel function is important to prevent complications like urinary tract infections (which can cause or worsen delirium), it is not the most immediate priority over managing the acute confusion and ensuring safety.
- Option C: Restoring the sleep-wake cycle is a critical component of delirium management. However, it is an ongoing goal managed over a 24-hour period (e.g., promoting daytime activity, ensuring a quiet night). It is not a single, immediate priority action like reorientation.
- Option D: Poor nutritional status can be both a cause and a result of delirium. While important for long-term recovery, it is not the most pressing concern in the initial 24-48 hours compared to the immediate risk of harm from confusion and agitation.
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 it using screening tools like the Confusion Assessment Method (CAM).
- The primary nursing role is to create a safe and therapeutic environment, focusing on non-pharmacological interventions before considering chemical or physical restraints, which should be a last resort.
- What if? If the patient was experiencing severe hyperactive delirium with aggression, the immediate priority would shift to de-escalation and ensuring physical safety for both the patient and staff (e.g., calling for a security code, one-to-one supervision), while simultaneously attempting reorientation.
How to Approach the Question
- First, identify the question type: This is a priority-based question set in a clinical scenario.
- Identify the core diagnosis and its primary feature: The diagnosis is delirium, which is an acute confusional state.
- Apply a prioritization framework. For patients with acute confusion, patient safety is always the highest priority.
- Evaluate each option based on how directly and immediately it promotes safety.
- Option A (Orientation) directly addresses the confusion to reduce anxiety and prevent unsafe behaviors.
- Options B, C, and D (elimination, sleep, nutrition) are all important supportive measures but are secondary to establishing immediate safety in a confused and potentially agitated patient.
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 indicates an acute confusional state, making safety the primary concern.
- Clinical cues: The timeframe of 'first 24 to 48 hours' emphasizes the need for immediate, foundational interventions.
Question ID
QKfEFI6z4JiW-aBwYLLOf6
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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