# Situation: A 29-year-old man is admitted to the psychiatric unit of a general hospital after 3 weeks of poor sleep and staying in his room. His family says he has no known medical illness and does not use alcohol or drugs. The nurse performs a mental status examination (MSE) on admission. By day 3 he is fully alert, correctly names the date and the place, and keeps his attention through the whole interview. He speaks clearly, but he still holds the fixed false beliefs noted on admission and draws illogical conclusions from everyday events. Which NANDA International (NANDA-I) 2024–2026 label BEST fits these data?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629989  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 29-year-old man is admitted to the psychiatric unit of a general hospital after 3 weeks of poor sleep and staying in his room. His family says he has no known medical illness and does not use alcohol or drugs. The nurse performs a mental status examination (MSE) on admission.

By day 3 he is fully alert, correctly names the date and the place, and keeps his attention through the whole interview. He speaks clearly, but he still holds the fixed false beliefs noted on admission and draws illogical conclusions from everyday events. Which NANDA International (NANDA-I) 2024–2026 label BEST fits these data?

## 보기

1. Impaired verbal communication
2. Disrupted thought processes **✔ 정답**
3. Acute confusion
4. Risk for acute confusion

**정답: 2**

## 해설

Disrupted thought processes describes a disturbance in the content and logic of thinking, such as fixed false beliefs and illogical reasoning, in a client whose consciousness, orientation, and attention are intact. Acute confusion requires an abrupt disturbance of consciousness, attention, and orientation, which he does not have.

## 심화 해설

Mental status examination (MSE) data and the NANDA-I label

The question asks you to match specific MSE findings with the most accurate NANDA-I nursing diagnosis. The key data are that by day 3 the client is fully alert, has intact orientation to date and place, and can sustain attention through the entire interview. At the same time, he continues to hold fixed false beliefs and draws illogical conclusions from ordinary events.

The core distinction is between a disturbance in the content and logic of thinking versus a disturbance in the level of consciousness, attention, and orientation. Fixed false beliefs and illogical reasoning are problems of thought *content* and thought *process*, not of arousal or awareness. Because the client is alert, oriented, and attentive, the disturbance is isolated to cognition itself. This pattern fits Disrupted thought processes, which describes a disturbance in cognitive operations and thought content—including delusions and impaired reasoning—while consciousness and orientation remain intact.

Watch out! Acute confusion is not correct because it requires an *abrupt* disturbance of consciousness, attention, and orientation. This client demonstrates none of those features by day 3. Risk for acute confusion is also incorrect because the client is not currently confused and the question asks for a label that best fits the *existing* data, not a future risk. Impaired verbal communication is ruled out because the client speaks clearly; the problem is not the mechanics or clarity of speech but the illogical content of what he says.

The clinical validation study by Escalada-Hernández et al. supports the importance of defining characteristics for Disrupted thought process [1]. In that study, the diagnosis was validated among institutionalized elderly people using diagnostic test validity methods, including sensitivity and specificity of defining characteristics. Although the study population differs from this 29-year-old man, the methodological approach reinforces that this NANDA-I diagnosis is identified through observable cognitive features—such as delusional content and illogical thinking—rather than through changes in consciousness or orientation. The study’s emphasis on clinical validation of defining characteristics aligns with the MSE approach used in this scenario: the nurse systematically assesses cognition, thought content, and thought process to determine which nursing diagnosis is most accurate.

| NANDA-I label | Consciousness | Orientation | Attention | Thought content/process | Fits this client? |
| --- | --- | --- | --- | --- | --- |
| Disrupted thought processes | Intact | Intact | Intact | Disturbed (fixed false beliefs, illogical reasoning) | Yes |
| Acute confusion | Disturbed (abrupt) | Disturbed | Disturbed | May be affected secondarily | No |
| Risk for acute confusion | Intact currently | Intact currently | Intact currently | No current thought disturbance required | No (risk only, not current) |
| Impaired verbal communication | Intact | Intact | Intact | Speech clarity intact; problem is content, not communication ability | No |

Key point! When a client is alert, oriented, and attentive but demonstrates delusions or illogical reasoning, the nursing diagnosis is Disrupted thought processes, not Acute confusion. The defining feature of acute confusion is an abrupt change in consciousness and attention, which this client does not show. The MSE is the clinical tool that separates these diagnoses by systematically evaluating each cognitive domain.References (research sources)

- [1]Defining Characteristics and Aetiological Factors of the Nursing Diagnosis Disrupted thought process: A Clinical Validation Study.Research articleEscalada-Hernández P, Soto-Ruiz N, San Martín-Erice I, Furtado-Eraso S, Molina-Pérez C, García-Vivar C (2026) · DOI: 10.1177/20473087261460987

## 임상 시나리오

NANDA-I Thought Process DiagnosisMSE findings and nursing diagnosis selection
Disrupted thought processes is the correct label when the client has delusions or illogical reasoning but remains alert, oriented, and attentive.

Acute confusion requires an abrupt disturbance of consciousness, attention, and orientation; intact cognition on these domains rules it out.

CautionDo not choose Risk for acute confusion when the question asks for a label fitting current data; risk diagnoses address future vulnerability, not present findings.

## 핵심 개념

- **Disrupted thought processes** — NANDA-I diagnosis describing disturbance in cognitive operations and thought content, such as delusions or illogical reasoning, with intact consciousness and orientation.
- **Acute confusion** — NANDA-I diagnosis requiring abrupt disturbance of consciousness, attention, and orientation.
- **Mental status examination (MSE)** — Structured assessment of appearance, behavior, speech, mood, thought process, thought content, cognition, and insight.
- **Fixed false beliefs** — Delusions; firmly held beliefs not amenable to logic or contradictory evidence, reflecting a thought content disturbance.
- **Illogical reasoning** — Drawing conclusions that do not follow logically from evidence, reflecting a thought process disturbance.

## 같은 주제 문제

- [Situation: A 29-year-old man is admitted to the psychiatric unit of a general hospital aft…](https://mymerci.kr/pages/nclex_q.php?qn_id=629986)
- [Situation: A 29-year-old man is admitted to the psychiatric unit of a general hospital aft…](https://mymerci.kr/pages/nclex_q.php?qn_id=629987)
- [Situation: A 29-year-old man is admitted to the psychiatric unit of a general hospital aft…](https://mymerci.kr/pages/nclex_q.php?qn_id=629988)
- [Situation: A 52-year-old man is seen at the outpatient mental health clinic of a provincia…](https://mymerci.kr/pages/nclex_q.php?qn_id=629990)
- [Situation: A 52-year-old man is seen at the outpatient mental health clinic of a provincia…](https://mymerci.kr/pages/nclex_q.php?qn_id=629991)
- [Situation: A 52-year-old man is seen at the outpatient mental health clinic of a provincia…](https://mymerci.kr/pages/nclex_q.php?qn_id=629992)
- [Situation: A 40-year-old woman is admitted to the psychiatric ward with major depressive d…](https://mymerci.kr/pages/nclex_q.php?qn_id=629993)
- [Situation: A 40-year-old woman is admitted to the psychiatric ward with major depressive d…](https://mymerci.kr/pages/nclex_q.php?qn_id=629994)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._