Nokea
The nurse is calling a report to the emergency department from a long-term care facility. The nurse states that the client abruptly experienced a change in mentation including disorientation and confusion. Vital signs are: temperature, 102.2?°F; pulse rate, 88 beats/minute; respiratory rate, 24 breaths/minute, and blood pressure, 152/70 mm Hg. Lungs are clear. Which potential diagnosis would the emergency department physician place in the initial documentation?
Correct Answer: A
Rationale: There is evidence in the stated report that the client is experiencing delirium. Delirium is a sudden, transient state of confusion. Clients with delirium have difficulty processing information. They may be disoriented, confused, and have impaired judgment. Many times, delirium is associated with a high fever, head trauma, brain tumor, drug intoxication or withdrawal, or inflammatory/metabolic disorders of the central nervous system. Alzheimer disease, with dementia being its most common symptom, is a progressive, deteriorating brain disorder. Disorientation is a symptom, not a diagnosis.