A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. The client can state the name and address but has no recollection of the past 2 days. What is the priority nursing action?

Question

Quizplus · Accepted Answer

This client is experiencing amnesia of undetermined origin. The cause could stem from a medical condition, substance abuse, traumatic brain injury, cognitive disorder such as dementia, or psychiatric condition such as dissociative fugue. Regardless of the diagnosis, the priority nursing action is to assess the client's physical status. This client has been wandering for 2 days and cannot recall previous locations, arriving at the present location, and the timetable involved. It is highly probable that the client is dehydrated and fatigued. It is most important to assess the client's physical needs and implement interventions to stabilize the physiologic condition before assessing psychosocial status and needs. (Option B) It is appropriate to contact this client's family members. However, this is not the priority nursing action. (Option C) This client may never be able to remember the events of the past 2 days. Encouraging a client to remember something when there is no sign of recollection may only increase client frustration. (Option D) A mental status examination is an important component of the nurse's assessment. However, it is not the priority assessment. Educational objective: Assessment of a client's physiologic status and needs is the priority nursing action when the client is suffering from amnesia with no recollection of where he has been or what he has been doing for a period of time. Interventions need to be implemented to stabilize the client physically before psychosocial needs are addressed.

A 60-Year-Old Client Wanders Away During Halftime at a Football