The primary caregiver of an elderly patient contacts the nurse at the outpatient clinic due to a sudden change in the patient’s behavior. The caregiver informs the nurse that the patient, who is usually oriented and able to answer Questions, is now confused and agitated. What actions should the nurse take? (Select all that apply)

Choice A rationale A sudden change in behavior, especially confusion and agitation, in an elderly patient could be a sign of a urinary tract infection (UTI). Pain during urination is a common symptom of UTIs. Therefore, it is crucial to inquire if the patient is experiencing any pain during urination. Choice B rationale While a high-protein diet can be beneficial for some patients, there is no direct link between increased protein intake and the alleviation of confusion or agitation in elderly patients. Therefore, this option is not a necessary immediate action for the nurse to take. Choice C rationale Reviewing the patient’s current food and medication allergies is important. Certain medications or foods might cause adverse reactions, including confusion and agitation. Therefore, it is crucial to review the patient’s allergies to rule out any potential allergens as the cause of the sudden change in behavior. Choice D rationale A recent fall could potentially lead to a head injury, which might cause confusion and agitation. Therefore, it is important to determine if the patient has recently experienced a fall. Choice E rationale Providing instructions on how to take the patient’s temperature is important. Fever could be a sign of an infection or other medical condition that might cause confusion and agitation. Therefore, knowing how to accurately measure the patient’s temperature can help monitor the patient’s condition.