A 76-year-old client was recently admitted to a rehabilitation unit. The client's adult child tells the practical nurse, "My parent was completely alert at home, but since yesterday, they are suddenly very disoriented, restless, and seeing things that are not there. I suppose this is a normal part of aging and transitioning to a new facility." Which action should the practical nurse take first?
- AReassure the adult child that sudden disorientation is an expected developmental response when an older adult relocates to a new environment.
- BExplain that dementia symptoms frequently worsen during life transitions and document the client's baseline mental status.
- Obtain the client's current vital signs, including oxygen saturation, and promptly notify the supervising registered nurse.Answer
- DAsk the family to bring familiar items from home to help the client adjust to the psychosocial transition.
Answer
Obtain the client's current vital signs, including oxygen saturation, and promptly notify the supervising registered nurse.
Sudden, acute onset of confusion, restlessness, and hallucinations are key indicators of delirium, which is a medical emergency often caused by underlying physiological issues like infection, hypoxia, or medication toxicity. It is never a normal developmental transition or an expected part of the aging process. The practical nurse must immediately collect physiological data (such as vital signs and oxygen saturation) and report these acute changes to the registered nurse for further assessment and intervention.
Step-by-Step Solution
Key Concept
Differentiating Acute Delirium from Normal Aging Transitions