When assisting with PM care for an 82-year-old client recuperating from pneumonia, the nurse observes that the client appears to be uncharacteristically confused, asking "Where am I?"
Which of the following interventions is the most therapeutic for this particular client?
1. Listen for lung sounds.
2. Reorient the client to place.
3. Ask some simple questions to confirm the confusion.
4. Assess the client's pulse oximetry reading on room air.
ANS: 4
Because mental status changes are often the first signs of respiratory problems and often include forgetfulness and irritability, assessing the client's blood oxygen is the most therapeutic interven-tion.
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