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Difficulty: EasyPhysiological Adaptation

While providing evening care at a nursing facility, a practical nurse observes that a 78-year-old resident has suddenly become highly disoriented, verbally aggressive, and unable to recognize family members. The resident has a history of hypertension and osteoarthritis, with no previous cognitive deficits. Which immediate actions should the nurse perform? (Select all that apply)

  1. Measure the resident's oxygen saturation and respiratory rate.Answer
  2. Perform a capillary blood glucose test.Answer
  3. Obtain the resident's current temperature and blood pressure.Answer
  4. D
    Explain to the family that sudden memory loss is an expected part of the normal aging process.
  5. E
    Apply bilateral soft wrist restraints to ensure physical safety during the aggressive episode.
  6. F
    Provide a PRN sedative medication immediately to control the combativeness.

Answer

The nurse should immediately measure oxygen saturation, check the capillary blood glucose, and obtain a full set of vital signs to identify a physiological cause for the acute confusion.
Sudden confusion, combativeness, or disorientation in an older adult is a hallmark sign of delirium, which is frequently triggered by acute physiological alterations such as hypoxia, hypoglycemia, or infection. The practical nurse must prioritize immediate physiological data collection—including oxygenation status, blood glucose, and vital signs—to identify and report these life-threatening, reversible conditions to the RN or provider before making psychosocial assumptions.

Step-by-Step Solution

1
Analyze the clinical presentation.
The resident is experiencing a sudden, acute onset of confusion and aggression without a prior history of cognitive decline.
Recognizing that sudden mental status changes in older adults indicate delirium rather than dementia is critical for prioritizing care.
2
Prioritize physiological data collection.
The nurse plans to assess respiratory rate, oxygen saturation, and blood pressure.
Airway, breathing, and circulation (ABCs) must be evaluated first to rule out life-threatening hypoxia or shock causing the altered mental state.
3
Assess for other common acute systemic triggers.
The nurse prepares to check the resident's temperature and blood glucose levels.
Infection (such as a urinary tract infection) and hypoglycemia are highly frequent, reversible physiological causes of sudden delirium in older adults.

Key Concept

Recognizing and collecting data on the physiological causes of acute delirium
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Topics

Physiological Adaptation

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