An 85-year-old client who has moved to a new town makes an ...

[frankwu]

An 85-year-old client who has moved to a new town makes an appointment for a routine annual assessment with a new primary care provider. The nurse plans to:
 
  1. Allow extra time for the assessment.
   2. Ask the client to bring a younger family member.
   3. Conduct a focused assessment.
   4. Visit the client's home prior to the assessment.

Question 2

Which of the following statements would be most important for the nursing staff to consider when planning delirium management for a client?
 
  1. Provide education for family members as needed
   2. Decrease all stimulation in the client's room
   3. Sensory deprivation and over stimulation can worsen symptoms
   4. Ask the family to involve the client in all conversations and interactions

[Tonyam972]

Answer to Question 1

1. Allow extra time for the assessment.

Rationale:
The very elderly client has trouble with recent memory, slower thought processes, slower movements, and fatigues easily. The nurse plans extra time so the client does not get overly tired and has time to formulate thoughts. It cannot be assumed that the elderly client cannot manage personal affairs, only that more time is needed. An annual assessment is a total assessment. Visiting the client is not the role of the nurse working for a primary care physician. However, the nurse might call the client and send a health form that the client can fill out with no pressure prior to the appointment.

Answer to Question 2

3. Sensory deprivation and over stimulation can worsen symptoms

Rationale:
The structure of the client's environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when over stimulated.

[frankwu]

Excellent

[isabelt_18]

TYSM