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Which of these Assessment Findings this morning suggest delirum, and why is it important to know for nursing? Increased fatigue over the past 3 days Alert and oriented X 2-disoriented to place this morning Anxious and distressed Dyspnea and SOB Accessory muscle use Breath sounds diminished to bases bilaterally Productive cough with green blood-tinges sputum—difficulty expectorating Expiratory wheeze bilaterally Barrel chest Skin is pale, hot and dry Strong peripheral pulses Urine is clear and concentrated with U/O 100 cc overnight Intermittent chills Fingernails are yellow with clubbing present
Which of these Assessment Findings this morning suggest delirum, and why is it important to know for nursing?
- Increased fatigue over the past 3 days
- Alert and oriented X 2-disoriented to place this morning
- Anxious and distressed
- Dyspnea and SOB
- Accessory muscle use
- Breath sounds diminished to bases bilaterally
- Productive cough with green blood-tinges sputum—difficulty expectorating
- Expiratory wheeze bilaterally
- Barrel chest
- Skin is pale, hot and dry
- Strong peripheral pulses
- Urine is clear and concentrated with U/O 100 cc overnight
- Intermittent chills
- Fingernails are yellow with clubbing present
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