medium · NCLEX-RN Psychosocial Integrity
A nurse is caring for an older adult client who is being treated for a urinary tract infection. The client's family reports that the client is usually 'sharp as a tack' but is now confused and thinks they are at a train station.
Which action should the nurse take first?
- Perform a focused assessment including T, BP, and SpO_2, as the next nursing response.
- Document the client's confusion as a normal age-related change associated with the current illness.
- Request a prescription for a low-dose antipsychotic to manage the client's agitation.
- Reorient the client to the current time, place, and situation using a calendar and clock.
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