Question

An 84-year-old female is brought to the E.R. presenting with confusion, restlessness and altered mental status. Which nursing action is appropriate? A. Ask the client about the medications she is currently taking. B. Give electrolyte replacing fluids. C. Refer the client for a psychiatric evaluation. D. Prepare for a physical exam including a chest \(x\)-ray; \(E K G, U A\), and \(C B C\).

Short answer

D. Prepare for a physical exam including a chest x-ray; EKG, UA, and CBC.

Step-by-step solution

- Identifying Symptoms

The patient is presenting with confusion, restlessness, and altered mental status. These are critical symptoms that need immediate and thorough assessment.

- Considering Immediate Actions

Consider what immediate steps will help in assessing the patient's condition comprehensively. Gathering information and diagnostic testing can provide valuable insights.

- Evaluating Options

Review each option for appropriateness: A. Asking about medications can provide insights but may not be comprehensive enough for immediate assessment. B. Giving electrolytes can be crucial but should be informed by diagnostic results. C. Psychiatric evaluation might not address potential physical causes. D. Preparing for physical exams and tests addresses a broad range of potential issues.

- Selecting the Best Action

Option D prepares for a comprehensive physical exam, including necessary tests (chest x-ray, EKG, UA, CBC) which can provide a well-rounded understanding of the patient's condition.

Key concepts

Nursing Intervention

Nursing interventions are immediate actions taken by nurses to address patient needs. They’re essential in responding to symptoms like confusion and altered mental status. Effective interventions involve:

• monitoring vital signs,
• administering medications,
• ensuring patient safety,
• providing psychosocial support.

In the given exercise, preparing the patient for a comprehensive physical exam is a crucial nursing intervention. It helps diagnose underlying issues leading to altered mental status. Paying attention to the patient’s immediate needs and being ready for rapid action can significantly impact patient outcomes.

Patient Evaluation

Patient evaluation involves collecting detailed information to understand the patient's health status. In the case of altered mental status, comprehensive evaluation is key. Nurses often assess the following areas:

• medical history,
• current medications,
• neurological status,
• environmental factors.

For an 84-year-old presenting with confusion, gathering information about her medications is vital but not enough. Multiple factors, such as infections or electrolyte imbalances, could cause altered mental status. A structured evaluation helps in developing a targeted care plan.

Emergency Care Protocols

Emergency care protocols guide nurses in providing timely and effective care during critical situations. For altered mental status, protocols may include:

• initial assessment and stabilization,
• administering necessary fluids or medications,
• initiating diagnostic tests,
• ensuring patient safety and comfort.

In this scenario, option D follows emergency care protocols. Preparing for tests like chest x-ray, EKG, UA, and CBC can rapidly identify potential causes of confusion. Implementing protocols ensures systematic and efficient care, leading to quicker diagnosis and treatment.

Diagnostic Testing

Diagnostic testing is crucial for identifying the root cause of symptoms such as confusion and restlessness. Tests that can be particularly informative include:

• Chest x-ray – checks for respiratory issues or infections.
• EKG – assesses heart function.
• Urinalysis (UA) – detects urinary tract infections or other abnormalities.
• Complete Blood Count (CBC) – identifies infections, anemia, or other blood disorders.

In the example, preparing for these tests is the most appropriate action. Combined results can offer a comprehensive view of the patient's health, guiding the medical team in providing targeted treatment.