# Situation: A 78-year-old woman is admitted to the adult medical ward with community-acquired pneumonia. She fell at home 2 months ago. She also has type 2 diabetes, has a peripheral intravenous (IV) line, walks by holding on to the furniture, has a weak gait, and is oriented to her own ability. The ward uses the Morse Fall Scale and treats a score of 45 or more as high risk. On her second night, she is newly restless and disoriented, tries to climb out of bed, and pulls at her IV line. Her oxygen saturation is 88%, and the nasal cannula ordered at 2 L/min is found on her pillow. Her capillary blood glucose is 132 mg/dL (7.3 mmol/L), her temperature is 37.6 °C, and her bladder is not distended. Her daughter is in the waiting area. All of the following are appropriate. Which action should the nurse take FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629762  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 78-year-old woman is admitted to the adult medical ward with community-acquired pneumonia. She fell at home 2 months ago. She also has type 2 diabetes, has a peripheral intravenous (IV) line, walks by holding on to the furniture, has a weak gait, and is oriented to her own ability. The ward uses the Morse Fall Scale and treats a score of 45 or more as high risk.

On her second night, she is newly restless and disoriented, tries to climb out of bed, and pulls at her IV line. Her oxygen saturation is 88%, and the nasal cannula ordered at 2 L/min is found on her pillow. Her capillary blood glucose is 132 mg/dL (7.3 mmol/L), her temperature is 37.6 °C, and her bladder is not distended. Her daughter is in the waiting area. All of the following are appropriate. Which action should the nurse take FIRST?

## 보기

1. Check the intravenous site and cover the line with a protective sleeve
2. Stay with her and calmly reorient her to time, place, and person
3. Put the cannula back on and recheck her oxygen saturation **✔ 정답**
4. Ask her daughter to stay at the bedside through the night

**정답: 3**

## 해설

New restlessness and disorientation in an older adult with pneumonia suggest delirium, and the data point to one reversible cause: hypoxia after the cannula came off (glucose is normal, the bladder is not distended, and the fever is low-grade). Restoring oxygen treats both the cause of the behavior and an immediate threat to breathing, so it comes first. Reorientation, protecting the line, and family presence are good alternatives to restraint that follow.

## 심화 해설

Find the reversible cause first
This 78-year-old woman with pneumonia becomes newly restless and disoriented at night, tries to climb out of bed, and pulls at her IV line. A sudden change in attention and orientation in an older adult with an acute illness suggests delirium, and the first nursing task in delirium is to look for a cause that can be corrected quickly. The data point clearly to one: her ordered nasal cannula is lying on the pillow and her oxygen saturation is 88%. Hypoxia is both a likely cause of her confusion and an immediate threat to breathing, so putting the cannula back on and rechecking the saturation comes first.

Ruling out the other causes in the stem
The stem deliberately supplies data that exclude other common triggers of acute confusion. Her capillary blood glucose is 132 mg/dL (7.3 mmol/L), so hypoglycemia is not the cause. Her bladder is not distended, so urinary retention is unlikely. Her temperature is 37.6 °C, a low-grade fever that fits pneumonia but does not explain a sudden change on its own. Only the low saturation with the cannula off is both abnormal and immediately reversible.

| Possible cause | Data in the stem | Conclusion |
| --- | --- | --- |
| Hypoxia | SpO2 88%, cannula off | Likely cause; correct now |
| Hypoglycemia | Glucose 132 mg/dL | Ruled out |
| Urinary retention | Bladder not distended | Ruled out |
| Fever or sepsis | 37.6 °C | Low-grade; keep monitoring |

Why the other appropriate actions follow
The stem says all four options are appropriate, so the question is about order. Reorientation and a calm presence help a delirious client, but they do not correct the hypoxia that is driving her behavior. Checking and sleeving the IV site protects the line, yet the line is not the immediate danger. Asking her daughter to stay at the bedside is an excellent alternative to restraint for the rest of the night, particularly because she is at high fall risk on the Morse Fall Scale (previous fall, secondary diagnosis, IV line, and impaired gait). Each of these follows once oxygen is restored and the saturation is confirmed.

Watch out! Do not reach for restraint or sedation in a newly confused older client before checking oxygenation, glucose, pain, bladder, and infection. Restraint increases agitation and fall injury, and sedatives can worsen both hypoxia and delirium.

Exam takeaway
Key point! When behavior changes suddenly, treat it as a physiological problem until proven otherwise. In a client with pneumonia and an SpO2 of 88% with the cannula off, the first action is to restore oxygen and reassess; safety measures, family presence, and reorientation then complete the plan.

## 임상 시나리오

Sudden Confusion with Low OxygenDelirium in an older adult with pneumonia
New restlessness and disorientation at night in an acutely ill older adult suggest delirium. Look first for a reversible cause.

Her SpO2 is 88% with the cannula off, glucose is 132 mg/dL, and the bladder is not distended. Hypoxia is the cause to correct now: replace the cannula and recheck the saturation.

Then reorient her, protect the IV line, and ask her daughter to stay as an alternative to restraint, since her history and gait put her at high fall risk.

CautionDo not restrain or sedate a newly confused client before checking oxygenation; both can worsen hypoxia, agitation, and injury.

## 핵심 개념

- **Delirium** — An acute, fluctuating disturbance of attention and awareness caused by a medical condition, drug, or withdrawal.
- **Hypoxia** — An inadequate oxygen supply to the tissues that can cause restlessness and confusion before other signs appear.
- **Morse Fall Scale** — A fall risk tool scoring fall history, secondary diagnosis, ambulatory aid, IV access, gait, and mental status.
- **Alternative to restraint** — A measure such as family presence or close observation used to keep a client safe without physical restraint.

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