35. Over the past 36 hours following open heart surgery, a client has become increasingly restless and agitated, and demands that "the bird" be removed from the room. Which factors are most likely contributing to this client's mental status?
Select all that apply.
. Administration of norepinephrine (Levophed) IV for low blood pressure.
. Visitors have been limited in the ICU.
. Visual hallucinations.
. Status post open heart surgery.
. Frequent interruptions for lab tests and procedures.
Test-Taking Tip
Choose causes, not symptoms.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
. . . .
Answer 1 is correct because delirium may be related to the use of vasoactive drugs. Answer 2 is correct because delirium may be caused by a combination of factors, including sensory deprivation from the restriction of familiar visitors. Answer 3 is incorrect because the hallucinations are a symptom, not the cause. Answer 4 is correct because delirium can be related to major surgery. Answer 5 is correct because delirium may occur from sleep deprivation and sensory overload.