Question

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) Document the findings and continue to monitor.
B) Assess the client's pain level and treat if needed.
C) Perform a Mini-Mental Status Examination.
D) Assess the client for other signs of infection.

Answer 1

The nurse should assess the client for other signs of infection.

Step-by-step explanation:

The most appropriate action for the nurse to take in this situation is to assess the client for other signs of infection. The client's slightly confused state along with the vital sign measurements of a slightly elevated temperature, low blood pressure, increased pulse, and normal respiratory rate are all indicative of a possible infection. By assessing the client for other signs of infection, such as localized redness, warmth to the touch, or elevated white blood cell count, the nurse can gather more information to confirm the presence of infection and determine the appropriate course of action.