Question

a nurse is preparing to collect physical assessment data from an older adult client who has acute confusion. which of the following assessments should the nurse perform first?
auscultate lung sounds.
check skin turgor.
measure body temperature.
obtain blood pressure.

Explanation:

When dealing with a client with acute confusion, the nurse should first measure body temperature. Fever (elevated body temperature) can cause acute confusion (delirium) in older adults. It is a vital sign and a quick assessment that can reveal a potentially life - threatening condition (such as an infection) which may be the cause of the confusion. Auscultating lung sounds (could indicate respiratory issues), checking skin turgor (for hydration status), and obtaining blood pressure (for circulatory status) are also important but not the first - priority in this context as fever is a more likely and quickly assessable cause of acute confusion in this population.

Answer:

Measure body temperature.