Question

A nurse is collecting data from an older adult client who fell at home and is disoriented to time, place, and person. Which of the following findings should indicate to the nurse that the client is experiencing delirium?

1) Increased blood pressure
2) Decreased heart rate
3) Confusion and agitation
4) Clear and coherent speech

Answer 1

Confusion and agitation (Option 3) in the presented case would indicate the client is experiencing delirium, an acute cognitive disorder characterized by sudden onset of confusion and fluctuations in mental state.

Step-by-step explanation:

The client in this scenario is experiencing delirium, which is an acute cognitive disorder that is characterized by sudden onset of confusion, which may fluctuate throughout the day. Delirium often includes symptoms such as confusion and agitation, as well as potential alterations in consciousness and attention. Among the options provided, the finding that should indicate to the nurse that the client is experiencing delirium is "Confusion and agitation" (Option 3).

Increased blood pressure could indicate a variety of conditions, but it is not specific to delirium. Similarly, a decreased heart rate is not a hallmark feature of delirium. Lastly, clear and coherent speech would likely not be present in a client with delirium, as confusion and disorganized thinking are characteristic symptoms. Delirium is distinct from dementia, which is a chronic condition. Delirium requires prompt medical attention, as it can be triggered by a variety of factors, including infections, medications, and other medical or surgical conditions causing stress to the body.