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Difficulty: MediumDevelopmental Stages and Transitions

A practical nurse is providing care for a 75-year-old client who is recovering from a total knee arthroplasty. During morning rounds, the client, who was previously alert and oriented, suddenly becomes highly agitated, does not know their location, and insists they must leave immediately to pick up their young children from school. Which action should the practical nurse take first?

  1. A
    Document the sudden confusion as an expected, normal cognitive transition for older adults during hospitalization.
  2. B
    Immediately apply a soft vest restraint to keep the client securely in bed and protect the surgical site.
  3. C
    Ask the client, "Why do you think your children are at school? You are 75 and they are adults now."
  4. Obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.Answer

Answer

The correct action is to obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.
Sudden onset confusion and agitation in an older adult is a classic presentation of delirium, which is an acute medical emergency often triggered by physiological factors such as hypoxia, infection, or medication side effects. The practical nurse must prioritize obtaining baseline physiological data (vital signs and oxygen saturation) and immediately reporting these findings to the registered nurse so that the underlying cause can be promptly diagnosed and treated.

Step-by-Step Solution

1
Analyze the client's presentation to differentiate between expected aging transitions and acute pathological changes.
The sudden onset of agitation and disorientation in a previously alert older adult indicates delirium, not a normal developmental transition or expected aging process.
Recognizing that acute confusion is a physiological red flag ensures that life-threatening causes (such as hypoxia or infection) are prioritized over psychological reassurance.
2
Determine the priority intervention within the practical nurse's scope of practice.
The nurse must prioritize gathering objective physiological data (vital signs and oxygenation) and escalating the findings.
Delirium often has a reversible, underlying physiological cause. Collecting vital signs provides the registered nurse and primary care provider with essential data to direct immediate medical treatment.

Key Concept

Differentiating expected older adult developmental transitions from acute delirium
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Topics

Developmental Stages and Transitions

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