A nurse is assessing a client who has valvular dysfunction. Which of the following manifestations should the nurse anticipate? (Select All That Apply)

Answer: C. "I am not worried. This sort of thing happens all the time to us 'old people.'"

A. "I brought an updated list of all the medications he takes at home to help you and the doctors determine what the cause of this could be."
This response indicates understanding and proactive involvement in the client’s care. An updated medication list is crucial in evaluating potential causes of delirium, as certain medications or interactions can contribute to changes in mental status.

B. "I notified our family members that they should not come visit for a while, until they are better."
This statement reflects an understanding of the need for a calm environment for the client experiencing delirium. Reducing stimuli and visitors can help the client focus on recovery. It indicates the spouse is aware of the potential impact of social interactions on the client’s condition.

C. "I am not worried. This sort of thing happens all the time to us 'old people.'"
This response indicates a need for further teaching. It reflects a possible misunderstanding of delirium as a normal part of aging, which can be dismissive of the seriousness of the condition. Delirium is often a sign of underlying medical issues and should be treated with concern and urgency. Clients and their families need to understand that delirium is not a typical or benign occurrence and requires appropriate evaluation and intervention.

D. "I am trying to stay positive. I know that most people return to normal, but it is hard to see them like this."
This statement indicates a hopeful attitude while acknowledging the difficulty of the situation. It shows understanding that recovery is possible and reflects the spouse's emotional processing of the situation. Maintaining a positive outlook can be beneficial for both the client and the family during recovery.

A. "I stopped taking aspirin last week.": Stopping aspirin medication prior to surgery is often advised to reduce the risk of bleeding during and after the procedure. The nurse may confirm the timing of discontinuation with the client and verify if any other anticoagulant medications are being taken.

B. "I did not put my contact lenses in this morning.": Removing contact lenses before surgery is a routine precaution to prevent potential corneal abrasions or complications during the procedure. This statement indicates the client is following preoperative instructions.

C. "I took my blood pressure meds with a sip of water.": Taking blood pressure medications with a small amount of water is generally acceptable before surgery. However, the nurse may verify the specific medications the client is taking and their dosing schedule to ensure compliance.

D. "I had a cough and runny nose a couple days ago.": This statement requires further investigation as respiratory symptoms, such as cough and runny nose, may indicate an underlying respiratory infection. Infections can increase the risk of complications during surgery, such as anesthesia-related respiratory issues or postoperative infections. The nurse should assess the severity and duration of the symptoms, inquire about any fever or recent exposure to illnesses, and consider notifying the surgical team for further evaluation and decision-making regarding the client's surgical readiness.