An 86-year-old resident in an extended care facility will not leave her room until her hair is combed, her lipstick is on, and she is well groomed.

The resident is sociable and completely independent, but it is lunchtime before she is ready to leave her room.
Which plan should a nurse make regarding breakfast for this client?

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

Notify the health care provider to report and anticipate new orders.

This is because an oral temperature of 100.8° F (38.2° C) indicates a fever, which could be a sign of infection or inflammation in an elderly client.

A fever of this magnitude could also cause dehydration, confusion, or seizures in older adults.

Therefore, the nurse should notify the health care provider as soon as possible to determine the cause and treatment of the fever.

Choice B is wrong because covering the client with an additional blanket could increase the body temperature and worsen the fever.

The UAP should not recheck the temperature in two hours, but rather monitor it more frequently and report any changes to the nurse.

Choice C is wrong because charting the temperature on the vital signs sheet and reporting to the new shift coming on is not enough to address the urgency of the situation.

The nurse has a responsibility to act on abnormal findings and communicate them to the health care provider.

Choice D is wrong because assessing the client’s temperature rectally and comparing the results is not necessary and could cause discomfort or injury to the client.

Rectal temperatures are usually higher than oral temperatures by about 0.5° F (0.3° C), so this would not change the interpretation of the fever.

The normal range for oral temperature in adults is 97.6° F to 99.6° F (36.4° C to 37.6° C).