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Difficulty: MediumHealth Promotion and Disease Prevention

A practical nurse arrives at the home of an 82-year-old client to conduct a routine health promotion visit and administer a scheduled pneumococcal vaccine. The client's spouse expresses concern, stating that the client woke up this morning unable to identify the current year and appears uncharacteristically restless. The client's baseline cognition is fully intact. Based on these findings, which action should the practical nurse take first?

  1. A
    Reassure the spouse that sudden episodes of mild confusion are an expected part of the aging process.
  2. B
    Administer the pneumococcal vaccine as prescribed before the client becomes too agitated to cooperate.
  3. Withhold the vaccine administration and immediately contact the supervising registered nurse or provider.Answer
  4. D
    Ask the spouse if any sudden cultural dietary restrictions have been implemented that might cause the behavior.

Answer

The correct action is to withhold the vaccine and promptly notify the supervising registered nurse or healthcare provider about the acute cognitive change.
The correct response addresses the sudden onset of disorientation and restlessness, which are classic signs of delirium. Delirium in older adults often points to an acute underlying medical issue such as a systemic infection. Because vaccines should generally be deferred in the presence of moderate to severe acute illness, the priority is to withhold the immunization and immediately notify the healthcare provider or registered nurse for a thorough medical evaluation.

Step-by-Step Solution

1
Analyze the client's current clinical presentation compared to their baseline.
The client has a sudden, new onset of disorientation and restlessness.
Identifying acute changes is the first step in determining the priority of care.
2
Determine the clinical significance of new-onset confusion in an older adult.
Acute confusion represents delirium, which is often a symptom of an underlying moderate to severe acute illness (such as an infection).
Understanding that delirium is a medical emergency prevents the nurse from dismissing the symptom as normal aging.
3
Evaluate the appropriateness of the scheduled health promotion intervention (vaccination).
Vaccines are generally contraindicated or should be deferred during a moderate or severe acute illness.
Administering a vaccine during an acute illness can complicate the clinical picture and increase the risk of adverse reactions.
4
Select the safest, most immediate action within the practical nurse's scope of practice.
The nurse must withhold the vaccine and escalate the finding to the supervising nurse or provider.
The practical nurse is responsible for gathering data and reporting significant abnormal findings to ensure patient safety.

Key Concept

Prioritization of Care and Immunization Precautions in Older Adults
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Topics

Health Promotion and Disease Prevention

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