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Difficulty: EasyAging Process

A practical nurse provides care for a resident in a long-term care facility who typically ambulates independently and converses coherently. The nursing assistant reports that the resident woke up highly agitated, disoriented to place, and unable to follow simple directions. Which action should the practical nurse take next?

  1. A
    Apply bilateral soft wrist restraints to keep the resident safely in bed.
  2. Perform a targeted physical assessment to identify potential underlying physiological causes.Answer
  3. C
    Ask the resident directly why they are unable to follow directions this morning.
  4. D
    Document the behavioral change as an anticipated age-related cognitive alteration.

Answer

The correct action is to perform a targeted physical assessment to identify potential underlying physiological causes.
Sudden, acute changes in cognition and behavior indicate delirium, which is often a symptom of an underlying physical illness such as a urinary tract infection, hypoxia, or medication toxicity. Because this is not a normal part of the aging process, the nurse must assess the client physically to identify and address the reversible physiological cause.

Step-by-Step Solution

1
Analyze the client's baseline versus current presentation.
The resident has transitioned from being independent and coherent to highly agitated and disoriented overnight.
Recognizing a rapid, abrupt change in baseline mental status is crucial for identifying acute delirium.
2
Differentiate between normal age-related changes and acute pathological conditions.
The nurse identifies the sudden confusion as an abnormal finding indicating a potential physical illness, not a normal aspect of aging.
Age-related cognitive changes occur gradually over years; sudden changes suggest an immediate physiological stressor like an infection or hypoxia.
3
Determine the priority nursing intervention.
The nurse prioritizes a physical assessment to uncover the root cause of the sudden mental status change.
Identifying and treating the underlying medical cause is the primary way to resolve delirium and ensure client stability.

Key Concept

Differentiating normal aging from acute delirium
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Topics

Aging Process

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