The nurse cares for a group of clients at risk for lower respiratory infection. The nurse is most concerned about which clients? Select all that apply.
1. The client who reports feeling cold and having chills.
2. The client with a respiratory rate of 30 breaths/min.
3. The client with a heart rate of 120 beats/min.
4. The client with new onset confusion and incontinence.
5. The client with nighttime cough and nasal discharge.
1. The client who reports feeling cold and having chills.
2. The client with a respiratory rate of 30 breaths/min.
3. The client with a heart rate of 120 beats/min.
4. The client with new onset confusion and incontinence.
Explanation: 1. Fever may be absent in the older client because many older people have a lower basal temperature and will not exhibit a fever response in the face of infection. Abrupt onset of chills can be a presentation of pneumonia in the older adult client.
2. Many things can cause tachypnea or dyspnea, but the nurse is concerned that this client may have pneumonia.
3. New-onset of tachycardia is an important clue to an illness with both viral and bacterial pneumonia.
4. Subtle changes in behavior can indicate pneumonia in an older client. Older clients can present with atypical symptoms such as mental changes, falls, new-onset incontinence, or recent functional decline.
5. The client with nighttime cough and nasal discharge is more likely to indicate an upper respiratory ailment like rhinitis or sinusitis.
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