A primary caregiver of an older adult client calls the nurse at the outpatient clinic due to a sudden onset of changes in the client’s behavior. The caregiver reports to the nurse that the client normally is oriented and able to answer Questions but now is confused. What action(s) should the nurse take? Select all that apply.

Choice A rationale Sudden onset of confusion in an older adult could be a sign of a urinary tract infection (UTI). UTIs can cause delirium and behavioral changes in older adults. Therefore, asking if the client is experiencing any pain with urination could help identify a potential UTI. Choice B rationale While high protein foods are generally beneficial for health, there is no direct link between increased intake of high protein foods and sudden onset of confusion. Therefore, this option is not the most appropriate action in this situation. Choice C rationale Reviewing the client’s current food and medication allergies is always important in healthcare settings. However, it may not directly address the sudden onset of confusion unless the client has had a recent change in diet or medication that could have triggered an allergic reaction leading to confusion. Choice D rationale A recent fall could potentially cause a sudden change in mental status due to a head injury or other trauma. Therefore, determining if the client has recently experienced a fall is an appropriate action. Choice E rationale Fever can cause confusion, especially in older adults. Therefore, providing instruction on taking the client’s temperature can help the caregiver monitor for signs of infection that could be contributing to the client’s confusion.