A nurse is performing a mental status examination on an older adult client who has delirium.

Which of the following tools can the nurse use to assess the client’s attention span and concentration?

The correct answer is B.

Diphenhydramine.Diphenhydramine is an antihistamine and sedative medication that can causedeliriumin older adults, especially when used in high doses or for a long time.Delirium is a serious change in mental abilities that results in confused thinking and reduced awareness of the surroundings.It can be caused by various factors, such as infections, medications, surgery, or alcohol or drug use or withdrawal.Delirium can have serious consequences, such as increased risk of falls, complications, and death.

Choice A is wrong because acetaminophen is a pain reliever and fever reducer that does not usually cause delirium in older adults.

However, acetaminophen overdose can cause liver damage and altered mental status.

Choice C is wrong because metformin is an oral medication that lowers blood sugar levels in people with type 2 diabetes.

Metformin does not typically cause delirium in older adults.

However, metformin can cause a rare but serious condition called lactic acidosis, which can cause confusion and other symptoms.

Choice D is wrong because lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure and prevents heart failure.

Lisinopril does not usually cause delirium in older adults.

However, lisinopril can cause a rare but serious condition called angioedema, which can cause swelling of the face, tongue, or throat and difficulty breathing.

Normal ranges for some relevant laboratory tests are:.

• Albumin: 3.5-5.0 g/dL.

• Potassium: 3.5-5.0 mEq/L.

• Total cholesterol: <200 mg/dL.

• Hemoglobin: 13.5-17.5 g/dL for men; 12.0-15.5 g/dL for women.

The correct answer isA, B, C, D, and E.

All of these questions are relevant for conducting a psychosocial assessment of an older adult client who has recently retired from work.A psychosocial assessment is a process for learning about a client’s problems and needs, so that together you can create therapy goals and a plan for recovery.The information-gathering process should allow you to learn more about the client as a person, beyond just a diagnosis.

• Choice A is correct because it explores how the client feels about their retirement, which can be a major life transition that affects their identity, self-esteem, and sense of purpose.

• Choice B is correct because it assesses the client’s interests and hobbies, which can provide sources of enjoyment, stimulation, and meaning in their life.

• Choice C is correct because it evaluates the client’s social support network, which can influence their mental health, well-being, and coping skills.

• Choice D is correct because it identifies the client’s stressors and challenges, which can affect their mood, functioning, and quality of life.

• Choice E is correct because it examines the client’s physical and mental health issues, which can impact their ability to perform daily activities, manage their emotions, and adhere to treatment plans.

A comprehensive geriatric assessment is a multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socioenvironmental situation of older people.The comprehensive geriatric assessment specifically and thoroughly evaluates functional and cognitive abilities, social support, financial status, and environmental factors, as well as physical and mental health.Ideally, a regular examination of older patients incorporates many aspects of the comprehensive geriatric assessment, making the two approaches very similar.