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Zorluk: KolayMental Health Concepts

An older adult client, who is typically alert and oriented, is admitted to the medical unit with a suspected urinary tract infection. During the night shift, the practical nurse (PN) observes that the client has become acutely restless, is disoriented to place, and is attempting to pull out their intravenous (IV) line. Which action should the PN take first?

  1. Obtain the client's vital signs and check their oxygen saturation.Cevap
  2. B
    Document the confusion as an expected sign of age-related dementia.
  3. C
    Apply soft bilateral wrist restraints to protect the intravenous access.
  4. D
    Ask the client why they are trying to remove the medical equipment.

Cevap

The practical nurse should first obtain the client's vital signs and oxygen saturation to assess for underlying physiological causes of the acute confusion.
A sudden onset of confusion, restlessness, and disorientation in an older adult is a classic presentation of delirium. Delirium is frequently triggered by physiological factors such as an underlying infection, hypoxia, or electrolyte imbalances. The priority action for the practical nurse is to gather objective physiological data by checking vital signs and oxygen saturation to identify if there is an immediate physical compromise causing the behavioral change.

Adım Adım Çözüm

1
Identify the nature of the client's behavioral change.
The client is experiencing a sudden, acute onset of confusion and restlessness.
Sudden confusion in an older adult is a hallmark sign of delirium, which is typically caused by an underlying physiological issue such as hypoxia, infection, or medication side effects.
2
Determine the priority nursing action based on safety and the nursing process.
Data collection is required before implementing interventions.
Obtaining vital signs and oxygen saturation provides immediate, objective data to rule out life-threatening physiological causes, like a lack of oxygen to the brain or a worsening infection, before other actions are taken.

Anahtar Kavram

Recognizing Acute Delirium and Prioritizing Physiological Data Collection
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Mental Health Concepts

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