NR 340 CRITICAL CARE NURSING
Delirium
Latest Review Exam
Q&A
2024
,1. A 74-year-old male patient with a history of chronic obstructive
pulmonary disease (COPD) is admitted to the ICU with acute respiratory
distress. Over the next 24 hours, he becomes increasingly agitated and
disoriented. Which of the following is the most appropriate initial action?
A. Administer an antipsychotic medication.
B. Perform a thorough assessment for possible causes of delirium.
C. Restrain the patient for safety.
D. Increase the oxygen supply.
Answer: B. Rationale: A thorough assessment is crucial to identify and
treat the underlying causes of delirium, such as hypoxia, infection, or
medication effects, rather than solely managing the symptoms.
2. A nurse is caring for a patient in the critical care unit who has
developed hypoactive delirium. Which clinical manifestation is least
likely to be observed in this patient?
A. Reduced motor activity
B. Decreased responsiveness
C. Hallucinations
D. Hyperalertness
Answer: D. Rationale: Hypoactive delirium is characterized by reduced
motor activity and responsiveness, and may include hallucinations, but
hyperalertness is not a typical feature and is more associated with
hyperactive delirium.
3. When educating families of patients in critical care about delirium,
which statement should be included?
A. "Delirium is a permanent condition."
B. "Delirium can only be treated with medications."
C. "Delirium often has a fluctuating course, with periods of lucidity."
D. "Delirium is not common in the ICU setting."
Answer: C. Rationale: Families should be informed that delirium can
fluctuate and patients may have periods of lucidity. It is not necessarily
permanent and can be treated with both non-pharmacological and
pharmacological methods. Delirium is also quite common in the ICU.
4. In assessing a patient for delirium, which tool is considered the gold
standard for ICU patients?
, A. Mini-Mental State Examination (MMSE)
B. Confusion Assessment Method for the ICU (CAM-ICU)
C. Glasgow Coma Scale (GCS)
D. Richmond Agitation-Sedation Scale (RASS)
Answer: B. Rationale: The CAM-ICU is specifically designed for use in
the ICU setting to assess for delirium, taking into account the unique
challenges of critically ill patients.
5. A patient in the ICU is experiencing delirium with visual hallucinations.
Which of the following interventions is most appropriate to address this
symptom?
A. Cover the patient's eyes to prevent hallucinations.
B. Engage the patient in reality orientation.
C. Increase sedation to decrease the hallucinations.
D. Ignore the hallucinations as they are not real.
Answer: B. Rationale: Engaging the patient in reality orientation can
help mitigate the effects of hallucinations by providing reassurance and
helping to distinguish between hallucinations and reality.
6. Which non-pharmacological intervention is recommended to prevent
delirium in critically ill patients?
A. Frequent reorientation to time, place, and person.
B. Continuous infusion of sedatives.
C. Limiting family visitation to reduce stimulation.
D. Keeping the patient in a dimly lit room at all times.
Answer: A. Rationale: Frequent reorientation is a key non-
pharmacological intervention that can help prevent delirium by
maintaining cognitive engagement and awareness of surroundings.
7. A patient with delirium is experiencing severe agitation that poses a risk
to their safety. Which medication class is commonly used first-line to
manage this symptom?
A. Benzodiazepines
B. Antipsychotics
C. Opioids
D. Antidepressants
Answer: B. Rationale: Antipsychotics are often used as the first-line
treatment for agitation in delirium, as they can help manage psychosis and
Delirium
Latest Review Exam
Q&A
2024
,1. A 74-year-old male patient with a history of chronic obstructive
pulmonary disease (COPD) is admitted to the ICU with acute respiratory
distress. Over the next 24 hours, he becomes increasingly agitated and
disoriented. Which of the following is the most appropriate initial action?
A. Administer an antipsychotic medication.
B. Perform a thorough assessment for possible causes of delirium.
C. Restrain the patient for safety.
D. Increase the oxygen supply.
Answer: B. Rationale: A thorough assessment is crucial to identify and
treat the underlying causes of delirium, such as hypoxia, infection, or
medication effects, rather than solely managing the symptoms.
2. A nurse is caring for a patient in the critical care unit who has
developed hypoactive delirium. Which clinical manifestation is least
likely to be observed in this patient?
A. Reduced motor activity
B. Decreased responsiveness
C. Hallucinations
D. Hyperalertness
Answer: D. Rationale: Hypoactive delirium is characterized by reduced
motor activity and responsiveness, and may include hallucinations, but
hyperalertness is not a typical feature and is more associated with
hyperactive delirium.
3. When educating families of patients in critical care about delirium,
which statement should be included?
A. "Delirium is a permanent condition."
B. "Delirium can only be treated with medications."
C. "Delirium often has a fluctuating course, with periods of lucidity."
D. "Delirium is not common in the ICU setting."
Answer: C. Rationale: Families should be informed that delirium can
fluctuate and patients may have periods of lucidity. It is not necessarily
permanent and can be treated with both non-pharmacological and
pharmacological methods. Delirium is also quite common in the ICU.
4. In assessing a patient for delirium, which tool is considered the gold
standard for ICU patients?
, A. Mini-Mental State Examination (MMSE)
B. Confusion Assessment Method for the ICU (CAM-ICU)
C. Glasgow Coma Scale (GCS)
D. Richmond Agitation-Sedation Scale (RASS)
Answer: B. Rationale: The CAM-ICU is specifically designed for use in
the ICU setting to assess for delirium, taking into account the unique
challenges of critically ill patients.
5. A patient in the ICU is experiencing delirium with visual hallucinations.
Which of the following interventions is most appropriate to address this
symptom?
A. Cover the patient's eyes to prevent hallucinations.
B. Engage the patient in reality orientation.
C. Increase sedation to decrease the hallucinations.
D. Ignore the hallucinations as they are not real.
Answer: B. Rationale: Engaging the patient in reality orientation can
help mitigate the effects of hallucinations by providing reassurance and
helping to distinguish between hallucinations and reality.
6. Which non-pharmacological intervention is recommended to prevent
delirium in critically ill patients?
A. Frequent reorientation to time, place, and person.
B. Continuous infusion of sedatives.
C. Limiting family visitation to reduce stimulation.
D. Keeping the patient in a dimly lit room at all times.
Answer: A. Rationale: Frequent reorientation is a key non-
pharmacological intervention that can help prevent delirium by
maintaining cognitive engagement and awareness of surroundings.
7. A patient with delirium is experiencing severe agitation that poses a risk
to their safety. Which medication class is commonly used first-line to
manage this symptom?
A. Benzodiazepines
B. Antipsychotics
C. Opioids
D. Antidepressants
Answer: B. Rationale: Antipsychotics are often used as the first-line
treatment for agitation in delirium, as they can help manage psychosis and
