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Zorluk: OrtaAging Process

An older adult resident in a long-term care facility suddenly becomes withdrawn, disoriented to time, and begins pacing the hallway aimlessly. The resident's documented baseline status is alert, oriented, and highly engaged in daily social activities. Which action should the practical nurse take first?

  1. A
    Attempt to logically explain to the resident why they need to return to their room for safety
  2. B
    Document the behavioral changes as an expected progression of age-related cognitive decline
  3. Obtain a full set of vital signs and perform a focused assessment to identify potential acute illnessesCevap
  4. D
    Request a prescription for a mild sedative to prevent the resident from wandering and sustaining a fall

Cevap

The correct action is to obtain a full set of vital signs and perform a focused assessment to identify potential acute illnesses.
Sudden changes in cognition, such as acute confusion, disorientation, or agitation in an older adult, are hallmark signs of delirium rather than normal aging. Delirium is often triggered by an acute, reversible physiological issue such as an infection, dehydration, or medication adverse effect. The practical nurse must prioritize data collection by obtaining vital signs and completing a focused assessment to identify the physiological root cause.

Adım Adım Çözüm

1
Identify the change in the client's baseline neurological and behavioral status.
The client has transitioned from alert, oriented, and socially engaged to suddenly disoriented, withdrawn, and pacing.
Recognizing acute changes from a client's baseline is essential for early clinical intervention in the older adult population.
2
Differentiate between normal age-related changes and acute pathological processes.
The sudden onset of confusion and disorientation indicates acute delirium, not normal aging or dementia.
In older adults, delirium is frequently an atypical presentation of an underlying physiological issue, such as a urinary tract infection, dehydration, or hypoxia.
3
Select the priority nursing intervention based on the clinical findings.
The nurse must prioritize gathering objective physical data to help identify the root cause of the delirium.
Collecting a full set of vital signs and performing a focused physical assessment is the critical first step to ensure patient safety and guide further medical treatment.

Anahtar Kavram

Atypical Presentation of Illness in Older Adults (Delirium)
Tahmini Süre:1m 0s
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Konular

Aging Process

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