Family members bring their 78-year-old parent to an ambulatory care clinic. The client, who typically functions independently and has no history of cognitive deficits, has experienced a sudden onset of visual hallucinations, severe agitation, and urinary incontinence since waking up. The family is highly distressed, stating their belief that this is a rapid onset of age-related dementia. Which action should the practical nurse take first?
- ADocument the behavioral changes as expected milestones of advanced aging and cognitive decline.
- Obtain vital signs and prepare to collect diagnostic specimens, as these symptoms often indicate an acute, reversible condition.Cevap
- CSuggest applying physical restraints to the client's wheelchair to ensure safety during the clinic visit.
- DAsk the client, 'Why are you acting so agitated with your family today?' to determine the root cause of the distress.
Cevap
The correct action is to obtain vital signs and prepare to collect diagnostic specimens, as these symptoms often indicate an acute, reversible condition.
A sudden onset of confusion, agitation, and incontinence in an older adult is not a normal part of the aging process. These are classic signs of delirium, which is typically secondary to an acute, reversible physiological issue such as a urinary tract infection, hypoxia, or electrolyte imbalance. The nurse must prioritize assessing for these acute physical causes by obtaining vital signs and preparing for diagnostic testing.
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Differentiating normal aging from acute delirium