# An 82-year-old woman is admitted from a long-term care facility after a fall. Her baseline Mini-Mental State Examination score is 22/30. On day 2, she is restless, picking at her gown, and repeatedly says she needs to catch a bus. Her temperature is 38.1°C (100.6°F), pulse 104/min, and respirations 22/min. The nurse notes that she was calm and oriented to place this morning. Which two actions should the nurse take first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505792&lang=en  
> language: en  
> subject: Psychosocial Integrity  
> category: PSI

## Question

An 82-year-old woman is admitted from a long-term care facility after a fall. Her baseline Mini-Mental State Examination score is 22/30. On day 2, she is restless, picking at her gown, and repeatedly says she needs to catch a bus. Her temperature is 38.1°C (100.6°F), pulse 104/min, and respirations 22/min. The nurse notes that she was calm and oriented to place this morning. Which two actions should the nurse take first?

The nurse should first ::선택::obtain a urine specimen for culture and urinalysisadminister lorazepam 0.5 mg POrequest a STAT neurology consultationencourage the family to remain at the bedside and ::선택::implement a bed alarm and reorient the patient frequentlyadminister lorazepam 0.5 mg POrequest a STAT neurology consultationencourage the family to remain at the bedside.

## Explanation

The acute change in mental status with fluctuating attention and disorganized thinking, along with fever and tachycardia, suggests delirium. The priority is to identify and treat the underlying cause, such as infection, and ensure safety. Obtaining a urine specimen for culture and urinalysis assesses for a common reversible cause (urinary tract infection) in older adults. Implementing a bed alarm and frequent reorientation maintains safety while the workup proceeds. Administering a sedative may worsen delirium and is not first-line. Requesting a neurology consult is premature before basic evaluation. Encouraging family to stay can be helpful but is not the immediate priority over diagnostic and safety measures.

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