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Difficulty: MediumHealth Promotion and Disease Prevention

A practical nurse is reviewing the health status of four clients scheduled for routine health promotion and disease prevention interventions. For which client should the nurse withhold the planned intervention and immediately notify the supervising registered nurse?

  1. An older adult client scheduled to receive the seasonal influenza vaccination who presents with new, sudden-onset confusion and restlessness.Answer
  2. B
    A four-month-old infant scheduled for routine immunizations whose parent reports localized redness and mild swelling occurred after the previous doses.
  3. C
    A nine-month-old infant scheduled for a well-child developmental screening who is unable to walk independently or build a tower of blocks.
  4. D
    A middle-aged adult client scheduled for a cardiovascular screening who strictly adheres to a culturally specific plant-based diet.

Answer

The older adult client presenting with new, sudden-onset confusion and restlessness.
The correct answer identifies a client exhibiting signs of acute delirium. Sudden-onset confusion and restlessness in an older adult are abnormal and typically indicate an acute underlying medical condition, such as an infection or toxicity. The practical nurse must prioritize safety, withhold the scheduled immunization due to the presence of an acute illness, and immediately notify the registered nurse for further assessment.

Step-by-Step Solution

1
Evaluate each client's presentation to differentiate between expected findings, normal developmental stages, and acute medical concerns.
Three clients have expected or non-urgent findings, while one exhibits signs of an acute, potentially severe condition.
Health promotion interventions, such as immunizations, are contraindicated during acute moderate-to-severe illnesses.
2
Identify the clinical significance of sudden-onset confusion in an older adult.
Sudden confusion and restlessness are classic signs of acute delirium, which often indicates an underlying infection, hypoxia, or medication toxicity.
The nurse must prioritize physiological safety, withhold the intervention, and escalate care to the registered nurse for immediate medical evaluation.

Key Concept

Differentiating acute health deviations from expected findings during health promotion activities.
Estimated Time:1m 15s
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Topics

Health Promotion and Disease Prevention

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