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Difficulty: HardAging Process

A client in a subacute rehabilitation facility is day three post-operative following a right knee arthroplasty. The client, who previously required minimal assistance and was fully oriented, is now attempting to climb out of bed, sweating excessively, and speaking to deceased relatives. Which of the following is the priority action for the practical nurse (PN)?

  1. Perform a rapid focused assessment including vital signs, oxygen saturation, and capillary blood glucose.Answer
  2. B
    Reorient the client using a calm voice and document the new onset of postoperative dementia.
  3. C
    Obtain a prescription for a low-dose antipsychotic medication to ensure the client's physical safety.
  4. D
    Administer the prescribed as-needed opioid analgesic, assuming the agitation is secondary to severe surgical pain.

Answer

The priority action is to perform a rapid focused assessment including vital signs, oxygen saturation, and capillary blood glucose.
In the older adult population, a sudden change in mental status, such as new-onset hallucinations or agitation, is a hallmark sign of delirium. Delirium is considered a clinical emergency because it frequently indicates an underlying acute physiological problem, such as hypoxia, infection, medication toxicity, or hypoglycemia. The priority for the practical nurse is to gather objective physiological data through a focused assessment before attempting behavioral reorientation or requesting pharmacological interventions.

Step-by-Step Solution

1
Analyze the client's changing clinical presentation.
The client is experiencing a sudden, acute change in mental status and behavior (delirium) compared to their baseline.
Recognizing that acute confusion is not a normal part of the aging process is critical; older adults often present with delirium as the first sign of physiological compromise.
2
Determine the priority of care utilizing the nursing process and physiological prioritization.
Physiological data collection takes precedence over behavioral or pharmacological interventions.
In older adults, delirium frequently masks acute complications like hypoxia, infection, or metabolic imbalances that require urgent medical intervention.
3
Select the appropriate action within the PN scope of practice.
Performing a focused assessment gathers the necessary objective data.
The PN must collect baseline physiological data (vital signs, oxygenation, glucose) to report to the registered nurse (RN) or provider before implementing interventions.

Key Concept

Recognizing atypical disease presentation (delirium vs. dementia) in the older adult.
Estimated Time:1m 30s
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Topics

Aging Process

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