# A 70-year-old client living alone at home has been exhibiting increased confusion, agitation, and difficulty sleeping over the past week. The client frequently asks for deceased family members and becomes upset when told they are not available. What is the most important assessment the nurse should prioritize? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541799 > language: ko > subject: Growth & Development ## 문제 A 70-year-old client living alone at home has been exhibiting increased confusion, agitation, and difficulty sleeping over the past week. The client frequently asks for deceased family members and becomes upset when told they are not available. What is the most important assessment the nurse should prioritize? ## 보기 1. Perform a comprehensive physical examination to rule out underlying medical conditions **✔ 정답** 2. Evaluate the client's medication regimen for potential drug interactions or side effects 3. Assess for signs and symptoms of depression and feelings of hopelessness 4. Review the client's recent dietary intake and hydration status **정답: 1** ## 해설 Acute confusion and agitation in elderly require immediate medical evaluation to rule out infections, metabolic issues, or drug effects. Depression assessment is important but secondary after medical causes are excluded. ## 심화 해설 Clinical Presentation Analysis The client’s acute onset of confusion, agitation, sleep disturbance, and visual hallucinations (asking for deceased family members) over a one-week period is a classic presentation of delirium. Delirium is a multifactorial and potentially life-threatening syndrome characterized by an acute and fluctuating disturbance in attention, awareness, and cognition . In older adults, delirium is frequently the first and only sign of a serious underlying physiological derangement, such as infection, metabolic imbalance, or medication toxicity, rather than a primary psychiatric condition. Why Option 1 Is the Priority The most critical step in managing suspected delirium is identifying and treating the underlying medical cause. The Geriatric Emergency Department Guidelines 2.0 emphasize that delirium in older patients requires a systematic approach to risk stratification and diagnosis because it is rarely idiopathic in this population . A comprehensive physical examination serves as the foundation for this diagnostic workup. It allows the nurse to gather objective data—such as vital signs, oxygen saturation, lung sounds, and signs of dehydration or focal neurological deficits—that can point to conditions like pneumonia, urinary tract infection, or hypoxia. These conditions are common, easily overlooked triggers that directly cause the neurotransmitter imbalances responsible for the client’s cognitive and perceptual disturbances. Without a thorough physical assessment, these reversible causes may be missed, leading to prolonged delirium and increased morbidity. Differentiating Delirium from Other Conditions The remaining options, while clinically relevant, do not take precedence because they address potential contributing factors rather than the immediate, life-threatening etiology. - Option 2 (Medication Review): A medication review is a vital component of a delirium workup, as polypharmacy and drug interactions are significant risk factors . However, it is a secondary step. The physical examination is prioritized first to rule out acute physiological crises (e.g., sepsis, stroke) that require immediate intervention. Medication-induced delirium is often a diagnosis of exclusion after acute illness is ruled out. - Option 3 (Depression Screening): The client’s presentation might superficially resemble depression, particularly with the focus on deceased family members. However, the key differentiator is the acute onset and fluctuating course of symptoms, including agitation and sleep disturbance. Depression typically has a more gradual, progressive course with a pervasive low mood, not the acute confusional state described. A qualitative study on delirium care in nursing homes highlights that differentiating delirium from other neurodegenerative diseases and depression is a recognized challenge, and misattributing symptoms to a mood disorder delays critical medical treatment . - Option 4 (Dietary and Hydration Review): Dehydration and malnutrition are common contributors to delirium in vulnerable older adults. Assessing intake is important, but it is a component of the broader physical examination and history. The comprehensive physical assessment will reveal clinical signs of dehydration (e.g., poor skin turgor, dry mucous membranes, orthostatic hypotension) and will guide immediate repletion efforts more effectively than a dietary review alone. Pathophysiological Rationale Delirium is the final common pathway of multiple interacting pathophysiological processes, including neuroinflammation, neurotransmitter dysregulation (particularly acetylcholine deficiency and dopamine excess), and impaired cerebral oxidative metabolism. An underlying acute illness, such as a urinary tract infection, triggers a systemic inflammatory response. Inflammatory cytokines cross the blood-brain barrier, directly disrupting neuronal function and synaptic transmission. This explains why a comprehensive physical examination to detect the source of inflammation or metabolic stress is the indispensable first step. The systematic review on delirium risk profiles underscores that the etiology of delirium is complex and linked to specific physiological stressors, making the search for an underlying medical condition the cornerstone of nursing assessment . ## 임상 시나리오 Acute Confusion in Older Adults: Suspect Delirium FirstPrioritize the physical exam to identify life-threatening causes Any acute onset (over hours to days) of confusion, agitation, or hallucinations in an older adult is delirium until proven otherwise. It is a medical emergency reflecting a physiological insult to the brain. The first and most critical nursing action is a comprehensive physical examination. Focus on vital signs, O2 saturation, lung sounds, and signs of infection (e.g., UTI, pneumonia) or focal neurological deficits to identify the underlying medical trigger. CautionDo not assume a psychiatric cause. Delirium is rarely idiopathic in geriatric patients; a thorough physical assessment to rule out physiological causes like hypoxia or sepsis takes absolute priority over a detailed psychosocial or medication history. ## 핵심 개념 - **Delirium** — An acute, fluctuating disturbance in attention, awareness, and cognition, often caused by an underlying medical condition, medication, or substance withdrawal. - **Geriatric Emergency Department Guidelines 2.0** — Evidence-based recommendations emphasizing systematic risk stratification and diagnosis for older adults presenting with delirium, as it is rarely idiopathic. - **Neurotransmitter Imbalance** — A disruption in brain chemicals (like acetylcholine or dopamine) that underlies the cognitive and perceptual disturbances seen in delirium, triggered by physiological stressors. - **Comprehensive Physical Examination** — A head-to-toe assessment gathering objective data (vital signs, O2 sat, lung sounds, neurological checks) to identify the root cause of a condition. - **Multifactorial Syndrome** — A condition like delirium that arises from multiple contributing factors, requiring a broad assessment to identify all potential underlying causes. ## 같은 주제 문제 - [A 90-year-old client in a long-term care facility has been exhibiting increased confusion,…](https://mymerci.kr/pages/nclex_q.php?qn_id=541796) - [An 82-year-old client in a long-term care facility has been increasingly withdrawn and ref…](https://mymerci.kr/pages/nclex_q.php?qn_id=541797) - [A nurse is assessing a 45-year-old client who was recently discharged from the hospital af…](https://mymerci.kr/pages/nclex_q.php?qn_id=541798) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._