A nurse aide working in the geriatric unit's dining room tells the nurse that a patient who was oriented to time and place this morning is now confused about what day it is and why she's "here." The nurse appropriately directs the nurse aide to
a. take the patient back to her room and put her safely in bed.
b. place a falls risk identification bracelet on the patient and add the status care plan.
c. immediately take the patient's vital signs and report them to her.
d. reorient the patient to time and place fre-quently and document the patient's re-sponse.
C
A sudden change in an older adult patient's cognitive status is likely a symptom of a physiologic stressor such as an infection. The vital signs will allow the nurse to determine the presence of a fever or other deviation from the patient's baseline vitals. The patient may or may not need or wish to go to bed, but this does not provide any data for the nurse to evaluate. An ill patient may need to be on fall precautions, but again this does not provide data. Reorientation may be neces-sary, but if the patient has an illness, this needs to be taken care of.
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