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RN101 Question Bank
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Delirium (10 Questions)
1. Mme Tremblay, 82 years old, is currently hospitalized on Day 3 post-op for a hip fracture repair. The nursing assistant reports that Mme Tremblay has been very "easy" to care for today because she has been sleeping almost the entire shift, has barely touched her lunch tray, and stares blankly at the wall when awake. She answers questions with one-word mumbles and seems unable to focus on the conversation.
Vital Signs: BP 110/70, HR 88, SpO2 95%.
Question:
Based on these clinical manifestations, what do you suspect is happening to the patient?
*
She is experiencing severe fatigue due to the surgery and needs rest.
She is developing major depression related to her loss of mobility.
She is presenting with hypoactive delirium.
She is displaying signs of early-onset vascular dementia.
2. M. Gagnon, 79 years old, is brought to the ER by his daughter. She states, "My father has mild memory issues usually, but this morning he didn't know who I was, he was talking about the year 1960, and he couldn't pay attention to anything I said. It happened so fast!"
Question:
Which specific feature mentioned by the daughter confirms the likelihood of delirium rather than a progression of dementia?
*
It happened so fast.
The memory loss.
The disorientation to time (1960).
The fact that he is elderly.
3. Mme Roy, 88 years old, is a resident in a long-term care facility. She suddenly becomes agitated, paces the hallway, and accuses the staff of stealing her purse. This is a new behavior for her.
Medical History: Diabetes, Hypertension.
Question:
What is the priority nursing assessment to determine the cause of this behavior?
*
Consult the psychiatrist for a medication adjustment.
Review the menu to see if she ate too much sugar.
Isolate the patient in her room to decrease stimulation.
Assess the patient for fecal impaction or urinary retention/infection.
4. M. Boucher, 74 years old, is in the ICU with "Hyperactive Delirium." He is trying to pull out his IV line and his Foley catheter. He is shouting at the ceiling.
Medical Order: Restraints PRN.
Question:
According to nursing standards and ethical guidelines, what intervention must be attempted before applying wrist restraints?
*
Administer a high dose of Haloperidol immediately.
Ask a family member to sit with him or assign a constant observer (sitter) to the bedside.
Tell the patient firmly that if he pulls the tubes, you will tie him down.
Apply mittens (unsecured hand coverings) immediately.
5. Mme Lefebvre, admitted for pneumonia, points to the corner of the room and screams, "There is a man with a knife standing there! Help me!" She is visibly terrified and trembling.
Question:
What is the most appropriate response?
*
"Mme Lefebvre, there is nobody there. Look, I will walk to the corner to show you."
"You are just imagining things because of your fever."
"I do not see the man, but I can see that you are very frightened. I will stay here with you to keep you safe."
"Yes, I see him too, I will call the security guard to take him away."
6. M. Poirier, 85 years old, was admitted yesterday for a fractured ankle. He was alert on admission. Tonight, he is confused and picking at the air. You review his new medication orders.
Question:
Which medication administered this evening is the most likely trigger for his delirium?
*
Acetaminophen 650 mg PO.
Diphenhydramine (Benadryl) 25 mg PO.
Metformin 500 mg PO.
Normal Saline IV infusion.
7. You are the primary nurse for Mme Cloutier. You suspect she is suffering from delirium. You need to perform a standardized assessment to confirm your suspicion before notifying the physician.
Question:
Which assessment tool is the "Gold Standard" for detecting delirium?
*
The Glasgow Coma Scale (GCS).
The Braden Scale.
The MMSE (Mini-Mental State Examination).
The CAM (Confusion Assessment Method).
8. M. Lambert, 91 years old, is being admitted to your unit. He has severe cataracts and hearing loss. He appears anxious and is asking, "Where am I?" repeatedly.
Question:
What is the most effective nursing intervention to prevent the onset of delirium in this patient?
*
Keep the room dark and quiet to prevent overstimulation.
Speak loudly into his ear and leave the TV on.
Ensure he is wearing his glasses and hearing aids at all times when awake.
Administer a prophylactic dose of Lorazepam to calm his anxiety.
9. Mme Dubois has been experiencing delirium for 2 days. She is awake all night yelling and sleeps deeply during the day.
Question:
What intervention should be included in the care plan to restore her circadian rhythm?
*
Allow her to sleep as much as possible during the day to recover her strength.
Give her a strong sleeping pill at 22:00.
Keep the room dimly lit 24 hours a day to provide a consistent environment.
Keep the curtains open and lights on during the day; minimize noise and light at night.
10. The son of M. Fortin, a patient with acute delirium due to a severe urinary tract infection (UTI), is crying. He asks, "My father has lost his mind completely. Is he going to be crazy like this forever? Do I need to find a nursing home?"
Question:
What is the accurate information to provide to the son?
*
"Unfortunately, delirium usually triggers permanent dementia."
"Don't worry, he will be back to normal by tomorrow morning."
"It is hard to say, but usually, once the infection is treated, the confusion clears up, though it may take a few weeks."
"Yes, at this age, confusion is permanent."