When the nurse receives information that a client with delirium is being admitted to the unit,
the
nurse would expect to document assessment findings that include (more than one answer may be
correct)
A. unimpaired level of consciousness.
B. disorientation to place and time.
C. wandering of attention.
D. perceptual disturbances.
E. self-care competence.
F. stable autonomic signs.
B, C, D
Rationale: Option B is an expected finding. Orientation to person (self) usually remains intact.
Option C: Attention span is short, and difficulty focusing or shifting attention as directed is often
noted. Option D: Illusions and hallucinations are commonly experienced by clients with delirium.
Option A: Fluctuating levels of consciousness are expected. Option E: Self-care deficits are usually
noted. Option F: Autonomic signs, tachycardia, seating, flushing, dilated pupils, and elevated blood
pressure are often present.
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Scenario 3
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