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Soru

Zorluk: OrtaDevelopmental Stages and Transitions

Three days after moving into a residential care community, an 82-year-old client suddenly becomes highly restless, exhibits disorganized thinking, and cannot recognize the facility staff. The client's family assumes this is just the stress of the major life change. Which action should the practical nurse prioritize?

  1. A
    Reassure the family that this sudden confusion is an expected response to transitioning to a new environment.
  2. Obtain a complete set of vital signs and immediately notify the supervising nurse of the acute changes.Cevap
  3. C
    Secure the client in a specialized bedside chair with a lap belt to ensure safety.
  4. D
    Ask the client, 'Why are you acting so restless when you are perfectly safe in your new home?'

Cevap

The practical nurse should obtain a complete set of vital signs and immediately notify the supervising nurse of the acute changes.
Sudden onset of confusion, restlessness, and disorganized thinking are classic signs of delirium, an acute and potentially life-threatening medical condition often caused by infections, hypoxia, or metabolic imbalances. In older adults, these symptoms should never be dismissed as normal aging or stress from a life transition. The practical nurse's priority is to collect baseline data, such as vital signs, and report the acute change in condition to the supervising nurse or provider immediately.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and the family's concerns.
The client is exhibiting sudden, acute changes in cognition and behavior (restlessness, disorganized thinking, failure to recognize staff), which the family mistakenly attributes to the stress of moving.
Recognizing the difference between expected transition stress and acute pathology is essential for client safety.
2
Determine if the symptoms align with a normal developmental or life transition.
Sudden onset confusion is a classic presentation of delirium, an acute medical emergency often triggered by infection, hypoxia, or medication changes, not a normal transition.
Normalizing acute confusion delays critical medical interventions and can lead to severe client harm.
3
Identify the appropriate nursing action within the practical nurse's scope of practice.
The nurse must collect baseline physical data (vital signs) and report the findings to the RN or provider for a comprehensive medical assessment.
Immediate communication ensures the client receives prompt evaluation for underlying physiological causes of the delirium.

Anahtar Kavram

Differentiating acute pathological changes (such as delirium) from expected developmental and transition-related stress in older adults.
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Konular

Developmental Stages and Transitions

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