# An 84-year-old client admitted 2 days ago for a hip fracture repair was alert and oriented to person, place, and time yesterday afternoon. The client has no history of dementia or psychiatric illness, and the family states the client drinks one glass of wine a month. Since 0200, the client has been pulling at the IV line, cannot keep attention on a conversation, and reports insects on the wall; at 1000 the client is calmer but still disoriented to place. Temperature is 38.3°C, heart rate 98/min, blood pressure 132/78 mm Hg, and the client has not slept overnight. The indwelling urinary catheter drains cloudy, foul-smelling urine. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617420&lang=en  
> language: en  
> subject: Mental Health Concepts  
> category: PSI

## Question

An 84-year-old client admitted 2 days ago for a hip fracture repair was alert and oriented to person, place, and time yesterday afternoon. The client has no history of dementia or psychiatric illness, and the family states the client drinks one glass of wine a month. Since 0200, the client has been pulling at the IV line, cannot keep attention on a conversation, and reports insects on the wall; at 1000 the client is calmer but still disoriented to place. Temperature is 38.3°C, heart rate 98/min, blood pressure 132/78 mm Hg, and the client has not slept overnight. The indwelling urinary catheter drains cloudy, foul-smelling urine. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Progression of an undiagnosed dementia
Delirium from alcohol withdrawal
Late-onset primary psychotic disorder
Delirium from a urinary infection

Actions to take

Select 2
Apply soft wrist restraints to protect the IV
Give prescribed PRN lorazepam for agitation
Report the change and obtain urine studies
Request a psychiatric consult for hallucinations
Reorient often with family at the bedside

Parameters to monitor

Select 2
Inattention on CAM screen
CIWA-Ar withdrawal score
Body temperature
Long-term memory recall
Total hours of nighttime sleep

## Explanation

An acute, fluctuating change in attention from a documented normal baseline, together with fever and cloudy catheter urine, indicates delirium from infection. The nurse reports the change so the cause can be treated and uses nonpharmacologic reorientation with family. Minimal alcohol intake, no dementia, and no psychiatric history make the differentials unlikely, and benzodiazepines or restraints can worsen delirium.

## In-depth explanation

Quick answer
Delirium related to a urinary infection. Report the change and obtain the prescribed urine studies, and reorient the client often with family present. Monitor attention with the CAM screen and temperature.

Why this is correct
Dementia develops over months, and this client was fully oriented yesterday. Symptoms that begin overnight and fluctuate between 0200 and 1000, with inattention, point to delirium. Fever and cloudy, foul-smelling catheter urine identify a treatable cause. Reporting and urine studies start cause-directed treatment, and reorientation with family is first-line delirium care. Attention and fever show whether the delirium and infection are resolving.

Easy analogy or mental picture
Delirium is like a sudden power flicker in a house that had steady lights yesterday: look for the tripped breaker (infection), don't rewire the house (dementia label).

Memory hook
Sudden + fluctuating + inattention = delirium; hunt the cause, calm with people, not pills or ties.

NCLEX decision rule
Compare the client's current mental status with the documented baseline. An acute change is delirium until proven otherwise, and the priority is finding and treating the cause.

Why the other choices are wrong
Restraints are still seen in practice but increase agitation, injury, and delirium duration. Lorazepam and CIWA-Ar scoring fit alcohol withdrawal, which is unlikely with one glass of wine a month, and benzodiazepines worsen delirium in older adults. A psychiatric consult fits a primary psychosis, but new hallucinations with fever and inattention suggest a medical cause. Long-term memory recall tracks dementia, and hours of sleep are affected by many conditions, so neither directly tracks this delirium or its cause.

References
1MedlinePlus — DeliriumDelirium features, common causes such as infection, and management

## Clinical scenario

Scenario
An older adult who was oriented the day before develops fluctuating inattention, visual hallucinations, fever, and cloudy foul-smelling catheter urine, with no dementia, psychiatric, or significant alcohol history.

## Key concepts

- **Delirium** — An acute, fluctuating disturbance of attention and awareness caused by an underlying medical condition.
- **Confusion Assessment Method (CAM)** — A bedside screen for delirium that assesses acute onset, fluctuation, inattention, and disorganized thinking or altered consciousness.
- **Hyperactive delirium** — A delirium subtype with agitation, restlessness, and often hallucinations.

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