The nurse is assessing four hospitalized older adults on a medical- surgical unit. Each client has distinct factors that could contribute to acute cognitive changes.
Explanation & Rationale
A. Ms. Rivera: New sertraline and uncontrolled diabetes may contribute to vulnerability, but she is alert and oriented - risk is present but moderate. B. Mr. Wilcox: Hearing impairment and sensory deprivation (no hearing aids) + new cardiac monitoring can precipitate confusion, but no acute infection or sedative/anticholinergic exposure is described. C. Mr. Daniels: Postoperative status, IV morphine, immobility, and baseline mild cognitive impairment increase risk for delirium - substantial risk. D. Mrs. Tran: Multiple strong precipitating factors - advanced age, baseline dementia, acute infection (urosepsis/fever), current disorientation, plus medications with deliriogenic potential (benzodiazepine PRN and an anticholinergic like oxybutynin). This clustering of predisposing and precipitating factors places her at highest immediate risk and requires urgent attention.