An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action?

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Quizplus · Accepted Answer

This client is experiencing impairment in cognitive and psychomotor functioning and most likely has delirium brought on by the urinary tract infection. This is not an uncommon occurrence in elderly clients. The client's most immediate needs are safety and prevention of physical injury. Initially, the client should be placed in a room near the nurses' station with one-on-one supervision and frequent reorientation to time, place, and situation. As the condition improves, the client will continue to require frequent observation. (Option A) It is important for this client to be well hydrated; this can best be accomplished through IV fluids and electrolyte replacement but not by encouraging the client to increase fluid intake. (Option B) Clients who are agitated often try to get out of bed, even if it means climbing over the side rails. Keeping the bed elevated and side rails raised increases the risk of a fall or other injury as the client attempts to leave the bed. (Option D) A dark room could worsen the client's confusion, agitation, and disorientation. Lighting helps maintain orientation to the environment; the client's room should be well lit during the day, and dim nightlights should be used at night. Educational objective: Safety is a high priority for clients with delirium. Disorientation, confusion, agitation, and difficulty interpreting reality all increase the risk for physical injury. Close observation, including one-on-one supervision, is essential to ensure client safety.

An 87-Year-Old Client Has Been Admitted to the Hospital with Signs