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Difficulty: MediumData Collection Techniques

A practical nurse (PN) is performing a morning assessment on a 79-year-old client in a rehabilitation facility. The client's baseline mental status is alert and cooperative. Today, the client is acutely agitated, disoriented, and struggling to answer basic questions. Which data collection action should the PN prioritize?

  1. A
    Record the confusion as an expected age-related cognitive decline and plan to reassess later.
  2. B
    Conduct a focused pain assessment using a numeric scale before evaluating respiratory or circulatory status.
  3. Obtain the client's vital signs, including oxygen saturation, to identify potential physiological causes.Answer
  4. D
    Ask the client to explain why they are feeling upset to gather subjective data about their mood.

Answer

Obtaining the client's vital signs, including oxygen saturation, to identify potential physiological causes.
When an older adult experiences a sudden change in mental status, the priority is to rule out acute physiological causes such as hypoxia, infection, or metabolic imbalances. Obtaining vital signs and oxygen saturation provides immediate, objective data to assess the client's physiological stability before proceeding with other assessments.

Step-by-Step Solution

1
Identify the sudden change in the client's baseline mental status.
The client is experiencing acute agitation and disorientation.
Recognizing a deviation from baseline is the first step in clinical judgment.
2
Determine the potential causes of acute confusion in an older adult.
Acute confusion (delirium) is often caused by physiological factors such as hypoxia, infection, or medication reactions.
Understanding common etiologies guides the choice of data collection techniques.
3
Select the priority data collection technique based on ABCs (Airway, Breathing, Circulation).
Collecting vital signs and oxygen saturation is prioritized over psychosocial or pain assessments.
Physiological stability must be established first when a client presents with an acute change in condition.

Key Concept

Prioritizing physiological data collection for acute changes in mental status
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Data Collection Techniques

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