A nurse in the long-term care facility assesses an 86-year-old woman who has recently become lethargic and difficult to arouse. Her vital signs are all stable and within normal limits. Her breath sounds are diminished
Which action by the nurse should be the priority?
A) Call the family and give them an update.
B) Place her on high fall risk precautions.
C) Send her to the emergency department.
D) Tell the aides to keep an eye on her.
Ans: C
Atypical presentation is especially common in those who are older than 85 years. Changes in behavior or functioning and increased fatigue are common atypical presentations of infection (e.g., pneumonia or urinary tract infection). In addition, the expected manifestations of an infection, such as elevated temperature or specific complaints of pain or discomfort, may be absent. While the family should be made aware of the update on the condition, the care of the client is the priority. It is not appropriate to delegate this to the certified nursing assistant (CNA). Placing her on fall prevention does not address the assessment data.
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