UP NHM CHO 7 Sept 2022 (Shift-2)
Medical & Surgical Nursing
Medium
Expected immediate outcome after intervention in delirium patient:
Appeared in: UP NHM CHO 7 Sept 2022 (Shift-2)
Explanation
- The primary goal in managing acute delirium is ensuring patient safety due to high risks of falls, self-harm, and removal of medical devices.
- Delirium involves acute confusion, agitation, and fluctuating consciousness, making injury prevention the most immediate and critical priority.
- Building trust with the caregiver helps to calm the patient, reduce agitation and paranoia, and facilitates a safer environment for care.
Why Other Options Were Wrong
- Option B: Following a daily routine is a long-term goal aimed at restoring normalcy and cognitive function after the acute phase of delirium has stabilized.
- Option C: Achieving optimal functioning is the ultimate, long-term objective of the entire treatment plan, not an immediate outcome of initial interventions.
- Option D: Reducing hallucinations is a medical outcome that results from treating the underlying cause of delirium, not an immediate nursing priority over safety.
Related Visual
Clinical Relevance
- Nursing practice connection: Safe nursing care depends on performing Prioritization of nursing outcomes in the management of acute delirium in the correct sequence, documenting the action clearly, and monitoring for the expected response.
- In managing delirium, the nurse's first action is always to assess and secure the environment to prevent harm. This aligns with the fundamental principle of 'do no harm'.
- Patient safety interventions, such as one-to-one supervision (sitter), are more effective and humane than physical or chemical restraints, which can worsen delirium (SRC_2216, SRC_2218).
- What if the patient is in the ICU and mechanically ventilated? The priority remains safety, but interventions adapt. The ABCDEF bundle (Assess, Both awakening/breathing trials, Choice of sedation, Delirium assessment, Early mobility, Family engagement) is a key strategy to prevent and manage delirium in this setting (SRC_2216).
How to Approach the Question
- First, identify the core concept of the question: 'immediate outcome' for a 'delirium patient'. This signals a question about prioritization.
- Recall the characteristics of delirium: acute confusion, agitation, and risk of harm. This is a safety-critical condition.
- Apply a prioritization framework like Maslow's Hierarchy of Needs. Safety needs are fundamental and must be addressed before higher-level needs like routine or optimal function.
- Evaluate each option against the 'immediate safety' criterion. 'Free from injury' directly addresses this primary need.
- Eliminate options that represent long-term goals (following routine, optimal functioning) or are secondary outcomes of medical treatment (reduced hallucinations).
- Confirm that the chosen answer represents the most immediate and essential nursing priority for this vulnerable patient population.
Concept Tested & Keywords
- Concept Tested: Prioritization of nursing outcomes in the management of acute delirium.
- Stem keywords: delirium, immediate outcome, intervention
- Lead-in keywords: Expected immediate outcome
Question ID
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Reference Book
E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) p. 13836-13838
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. 227-229
Practise the full UP NHM CHO 7 Sept 2022 (Shift-2)
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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