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Difficulty: MediumData Collection Techniques

An adult child brings their 78-year-old parent to an urgent care clinic. The child reports to the practical nurse (PN) that the parent, who usually manages household tasks independently, has become abruptly disoriented, restless, and agitated over the last 24 hours. Which of the following actions should the PN implement during the data collection process? Select all that apply.

  1. Obtain a comprehensive set of vital signs, prioritizing oxygen saturation and body temperature.Answer
  2. Observe the characteristics of the client's urine and inquire about any recent changes in voiding habits.Answer
  3. Review the client's current medication list with the adult child to identify any newly added prescriptions.Answer
  4. D
    Document the sudden disorientation as an expected, age-related cognitive change that requires no further physical investigation.
  5. E
    Apply bilateral soft wrist restraints immediately to ensure the physical data collection can be completed safely.
  6. F
    Respond to the client's disoriented statements by repeatedly assuring them that there is absolutely nothing to worry about.

Answer

The correct actions include obtaining a comprehensive set of vital signs, observing urine characteristics, and reviewing the current medication list with the family.
Acute, sudden-onset confusion in an older adult is indicative of delirium, which is typically triggered by a reversible physiological stressor. Essential data collection techniques focus on identifying common causes: obtaining vital signs helps rule out hypoxia or systemic infection; observing urine characteristics screens for a urinary tract infection (a leading cause of delirium); and reviewing the medication list identifies potential drug toxicity or interactions.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is experiencing an abrupt onset (over 24 hours) of disorientation, restlessness, and agitation, which are classic signs of acute delirium.
Differentiating between acute delirium and gradual dementia determines the urgency and direction of the physical data collection.
2
Identify common, reversible causes of delirium in older adults.
Common physiological triggers include infections (especially urinary or respiratory), hypoxia, and adverse medication reactions.
This pathophysiological knowledge guides the PN to select appropriate data collection techniques, such as checking vital signs, assessing urine, and reviewing medications.
3
Evaluate the remaining options against practical nursing standards for safety and therapeutic communication.
Dismissing the confusion as normal aging, applying restraints prematurely, and offering false reassurance violate core nursing principles.
Ensures that all selected interventions prioritize evidence-based practice, client safety, and therapeutic engagement.

Key Concept

In older adults, sudden-onset confusion is a sign of acute delirium often caused by underlying physiological issues (e.g., infection, hypoxia, medication changes) and requires prompt physical data collection to identify the root cause.
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Data Collection Techniques

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