The nurse walks into the client room, and the client is confused and disoriented. Ten minutes prior, the client was oriented to person, place, and time and was not confused. Which nursing action is priority?
A)Position client in supine position
B)Assess vital signs and pulse oxygenation
C)Ambulate client to encourage lung expansion
D)Obtain urine for urinalysis

Question

Quizplus · Accepted Answer

A)Decreased O? reaching the brain may lead to cognitive impairment, coma, and death. A client demonstrating a rapid onset of confusion and disorientation will need to have vital signs, pulse oximetry, and airway assessed for signs of impaired perfusion. Ambulating a client demonstrating these symptoms would be premature and could cause additional harm if there is impaired oxygen perfusion. Although urinary tract infections may cause acute mental status changes, the priority action would not be to obtain urine for a urinalysis.
B)Decreased O? reaching the brain may lead to cognitive impairment, coma, and death. A client demonstrating a rapid onset of confusion and disorientation will need to have vital signs, pulse oximetry, and airway assessed for signs of impaired perfusion. Ambulating a client demonstrating these symptoms would be premature and could cause additional harm if there is impaired oxygen perfusion. Although urinary tract infections may cause acute mental status changes, the priority action would not be to obtain urine for a urinalysis.
C)Decreased O? reaching the brain may lead to cognitive impairment, coma, and death. A client demonstrating a rapid onset of confusion and disorientation will need to have vital signs, pulse oximetry, and airway assessed for signs of impaired perfusion. Ambulating a client demonstrating these symptoms would be premature and could cause additional harm if there is impaired oxygen perfusion. Although urinary tract infections may cause acute mental status changes, the priority action would not be to obtain urine for a urinalysis.
D)Decreased O? reaching the brain may lead to cognitive impairment, coma, and death. A client demonstrating a rapid onset of confusion and disorientation will need to have vital signs, pulse oximetry, and airway assessed for signs of impaired perfusion. Ambulating a client demonstrating these symptoms would be premature and could cause additional harm if there is impaired oxygen perfusion. Although urinary tract infections may cause acute mental status changes, the priority action would not be to obtain urine for a urinalysis.

The Nurse Walks into the Client Room, and the Client