An elderly client was admitted yesterday for dehydration. The client has an IV infusion and a Foley catheter. Today the client appears restless and will not eat. The client's vital signs are T 99.2° F, P 88 beats/min, R 20 breaths/min, BP mm Hg
The nurse should first assess the client further for a. an infection.
b. medication usage.
c. orientation status.
d. stroke/TIA.
A
All options would be part of a comprehensive assessment to determine the cause of a change in status. However, the elderly are very susceptible to infection and often do not exhibit usual signs and symptoms. This client has two obvious portals of entry for infection: the IV line and the ca-theter. Suspect infection in an elderly client with a temperature over 99° F, changes in mental status, worsening cognition, lethargy, agitation, loss of appetite, incontinence, or an increased tendency to fall.
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