While providing morning care in a subacute rehabilitation facility, a practical nurse notes that an 84-year-old client recovering from a hip replacement has suddenly become restless, is continuously pulling at their clothing, and is unable to answer simple questions. The client was alert and conversant the day before. Which conclusion is most appropriate for the nurse to make?
- AThe client is demonstrating the onset of dementia, which is considered a normal, expected physiological change in the aging process.
- BThe practical nurse should independently perform a comprehensive initial neurological assessment to medically diagnose the cause of the confusion.
- The client is exhibiting signs of delirium, an acute and potentially reversible state that often indicates an underlying physical complication.Cevap
- DThe client requires the immediate application of physical restraints to prevent them from moving and dislocating the new hip joint.
Cevap
The client is exhibiting signs of delirium, an acute and potentially reversible state that often indicates an underlying physical complication.
The correct answer identifies that a sudden change in mental status, such as restlessness and confusion, is a primary indicator of delirium. In older adults, delirium is often an atypical presentation of a physiological stressor, such as an infection (e.g., urinary tract infection or pneumonia), hypoxia, uncontrolled pain, or an adverse medication reaction. It is an acute, reversible condition that requires prompt identification and treatment of the underlying cause.
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Atypical Presentation of Illness in Older Adults