In an older client experiencing acute delirium, what is the priority nursing action?

• A. Assess the underlying cause of delirium and intervene accordingly
• B. Place the patient in restraints and monitor
• C. Administer sedatives to calm the patient
• D. Implement comfort measures only without investigating the cause

Answer: (A)

Delirium in an older adult is a medical emergency, so the priority is to identify and treat the underlying reversible cause. Delirium has many possible triggers—infection, dehydration, electrolyte or metabolic disturbances, hypoxia, organ failure, medication effects or withdrawal, pain, or environment changes—so promptly assessing for and addressing these etiologies can reverse the cognitive disturbance and prevent complications. The nursing approach should include a thorough assessment (vital signs, oxygenation, hydration status, pain, confusion level, medication review), safety measures, and initiating targeted interventions or diagnostics (labs, imaging, appropriate treatments) as indicated, while also providing orientation and a calming, supportive environment. Restraints or sedatives do not treat the cause and can worsen delirium or mask deterioration, and relying solely on comfort measures without investigating potential reversible triggers risks missing life-threatening conditions.