Problem
Is 7 o'clock, and you are working as a nurse on an inpatient general medical unit of a large urban hospital. A 65-year-old man, Sam, is admitted to your unit with symptoms of disorientation to time and place and he is intermittently exhibiting signs of agitation. He thinks you are his grandchild and falls asleep during your interview. When you ask him to sign a consent form, he reaches for his hair comb to sign the form.
a) What assessment techniques you would use to determine whether Sam has dementia, delirium, or both?
b) What nursing diagnoses would be pertinent for Sam?
c) What nursing interventions would you incorporate into Sam's care plan to promote comfort and safety?