An 86-year-old client is admitted to the emergency department from a long-term facility. The client has Alzheimer's disease, a history of falls with injury, atrial fibrillation, and a fever of unknown origin

Question

The chest x-ray reveals a possible area of consolidation in the right lower lobe. The client is restless, irritable, and agitated. For best practice, prioritize the actions the nurse would take. (Prioritize sequence.) 1. Review drugs and doses
2. Serve as client advocate
3. Communicate with long-term facility
4. Assess for comfort and safety
5. Investigate vague signs and symptoms

Answer 1

4. Assess for comfort and safety
5. Investigate vague signs and symptoms
3. Communicate with long-term facility
1. Review drugs and doses
2. Serve as client advocate

Rationale:
The first priority is to assess for comfort and safety because the nurse needs to establish a baseline to compare with later assessments and to determine the priority of interventions. Second, the nurse would investigate vague signs and symptoms because the presentation of illness in the older adult is often less dramatic than in the younger person, and signs and symptoms of heart disease, infection, gastrointestinal problems, depression, and cancer may not be accompanied by the classic signs and symptoms seen in younger adults. Third, the nurse would communicate with the long-term facility to learn the client's usual behavior, request information regarding client's medications and dietary preferences, and establish a rapport with the facility for future client needs. Fourth, the nurse would review drugs and dosages of the client's prescriptions, when the last doses were administered, and the interactions of drugs prescribed to prevent medication errors and risk of injury. Fifth, the nurse would serve as client advocate by practicing ethically according to professional standards; establishing directives and identifying end-of-life preferences; and educating and empowering the client and family so that they can make informed decisions, avoid futile care, and refuse interventions that are excessively burdensome, painful, and invasive.