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An older adult client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother that has been dead for many years. Which action(s) should the nurse take? Select all that apply.

A.

Review the client's current food and medication allergies.

B.

Encourage increasing the intake of high protein foods.

C.

Obtain the client's tympanic temperature measurement.

D.

Determine if the client has recently experienced a fall.

E.

Ask if the client is experiencing any pain with urination.

Answer and Explanation

Correct Answer : C,D,E

A. While knowing allergies is part of a general admission or intake process, it is not a priority diagnostic action for acute confusion. Allergies typically cause respiratory distress or skin reactions (anaphylaxis/urticaria), not sudden cognitive changes or hallucinations.

B. Encouraging increased intake of high-protein foods is not an immediate priority. While nutrition is important for long-term health, it does not address the urgent concern of acute confusion. Immediate assessment for potentially reversible causes takes precedence.

C. Obtaining a tympanic temperature measurement is crucial because infection can present atypically in older adults, sometimes only as confusion or behavioral changes rather than classic symptoms like fever. A urinary tract infection, pneumonia, or other systemic infection could be causing delirium, and detecting fever would guide timely intervention.

D. Determining whether the client has recently experienced a fall is important. Head trauma, even minor, can lead to acute cognitive changes, intracranial bleeding, or other complications. Older adults are particularly vulnerable, and history of falls must be assessed to rule out injury as a cause of confusion.

E. Asking if the client is experiencing pain with urination is important because urinary tract infections (UTIs) are a common cause of delirium in older adults, even when classic urinary symptoms like dysuria or frequency are absent. Early identification allows for rapid treatment and prevention of further complications.


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Related Questions

Correct Answer is B

Explanation

A. Atopic dermatitis is a chronic inflammatory skin condition that typically begins in childhood and may persist into adulthood. While older adults can have eczema, it is not an expected finding due to normal aging and is less common in this population, especially in someone without a prior history.

B. Lentigines, also called age spots or liver spots, are flat, brown macules that develop on sun-exposed areas of the skin, such as the face, hands, and forearms. Older adults with a history of extensive sun exposure, such as a retired farmer, are particularly prone to developing lentigines due to cumulative ultraviolet (UV) damage over the years. These lesions are benign and a normal finding in aging skin.

C. Tinea capitis is a fungal infection of the scalp most commonly seen in children. It is rare in older adults, and its presence would be considered abnormal rather than an expected age-related change.

D. Impetigo is a superficial bacterial skin infection, most frequently seen in young children or in individuals with poor hygiene or immunocompromise. It is not an expected lesion in healthy older adults and would indicate an acute pathological process rather than a normal aging change.

Correct Answer is ["B","C","E","G"]

Explanation

Rationale for correct answers:

  • Agitated: In the context of chest pain, agitation or a "sense of impending doom" is a clinical indicator of decreased cerebral perfusion or a sympathetic nervous system surge related to a myocardial infarction.
  • Reported chest pain described as pressure and tightness that is unrelieved with rest: Stable angina usually resolves with rest. Pain that is "unrelieved by rest" and has lasted longer than 20 minutes is a classic hallmark of unstable angina or an acute myocardial infarction.
  • Rapid and shallow breaths: A respiratory rate of 21 and a shallow pattern indicate respiratory distress. This may be a compensatory mechanism for low oxygen saturation (92%) or a result of the pain and anxiety associated with a cardiac event.
  • Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest: Any chest pain rated as severe (7/10) requires a STAT ECG and cardiac enzyme markers (Troponin) to rule out heart muscle damage.

Rationale of incorrect answers:

  • Alert and oriented person, place, time, and situation: This is a normal finding (A&O x4), showing that the client currently has enough cardiac output to perfuse the brain.
  • Radial and pedal pulses 2+: This is a normal finding, indicating that peripheral circulation is currently adequate and equal in all extremities.
  • Clear breath sounds throughout bilateral lungs: This is a "normal" finding in this context. While it’s good the lungs are clear (suggesting no immediate heart failure/pulmonary edema), it is not an abnormal cue that needs a change in the plan of care.

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