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Question

Difficulty: MediumAging Process

A practical nurse conducts a home visit for a 68-year-old client. The client's spouse states that the client awoke highly agitated, unable to focus, and confused about how to use the television remote control. Which action should the nurse take first?

  1. Obtain the client's vital signs and check oxygen saturation levels.Answer
  2. B
    Reassure the spouse that memory lapses and mood changes are expected variations of normal aging.
  3. C
    Recommend applying a soft waist restraint if the client attempts to leave the house unescorted.
  4. D
    Ask the client why they are feeling frustrated with the television remote control.

Answer

The correct action is to obtain the client's vital signs and check oxygen saturation levels.
Sudden changes in cognition, attention, and behavior in an older adult are indicative of delirium, an acute medical emergency often caused by underlying physiological issues such as hypoxia, infection (like a urinary tract infection), or medication adverse effects. By immediately obtaining vital signs, the practical nurse gathers essential baseline data to help identify potential physiological causes before promptly reporting to the registered nurse or healthcare provider.

Step-by-Step Solution

1
Analyze the client's symptoms and history.
The client has a sudden onset of agitation, inattention, and confusion.
Identifying whether symptoms are chronic (like dementia) or acute (like delirium) is essential for prioritizing care.
2
Determine the likely cause of the acute change.
Sudden cognitive changes in an older adult are hallmark signs of delirium.
Delirium is a medical emergency typically triggered by physiological factors such as hypoxia, infection, or medication toxicity.
3
Select the highest priority nursing action.
Gathering objective clinical data by taking vital signs.
Before contacting a provider, the nurse must assess the client's physiological status to identify potential life-threatening causes like hypoxia or sepsis.

Key Concept

Differentiating delirium from normal aging and prioritizing physiological assessment
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Topics

Aging Process

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