An older adult client is admitted with an infection. On assessment, the nurse finds the client slightly confused. Vital signs are as follows: temperature 99.2° F (37.3° C), blood pressure 100/60 mm Hg, pulse 100, and respiratory rate 20
Which action by the nurse is most appropriate? a. Perform a Mini-Mental Status Examina-tion.
b. Assess the client for other signs of infec-tion.
c. Document the findings and continue to monitor.
d. Assess the client's pain level and treat if needed.
B
Because of an age-related decline in immune function, an older adult's normal temperature may be 1° to 2° lower than normal. A temperature of 99.2° F may be a fever in this population. Often a change in mental status is an early sign of illness for the older adult. The nurse should assess for other indications of infection.
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