What is the recommended response to a change in a client's mental status?

• A. Reassess with appropriate tools, review medications, assess for delirium, notify clinician, and document.
• B. Increase physical activity immediately to stimulate mental alertness.
• C. Ignore the change unless it worsens significantly.
• D. Document the change and wait for a routine doctor's visit.

Answer: (A)

A change in mental status should be handled with a structured, timely response that aims to identify and treat delirium or other reversible causes. Start by reassessing the patient with appropriate cognitive tools to gauge the extent and nature of the change, which helps distinguish delirium from baseline conditions and other issues. Then review all medications and recent changes, since many drugs or drug interactions can trigger delirium or confusion. Look for common medical triggers as well—infection, dehydration, electrolyte imbalances, hypoxia, pain, urinary retention, or constipation—and assess specifically for signs of delirium, such as sudden onset with fluctuating attention and level of consciousness. If delirium or a significant change is suspected, promptly notify the clinician so they can evaluate, investigate underlying causes, and adjust treatment as needed. Finally, document the observations, assessment findings, actions taken, and any changes in medications to ensure clear communication and continuity of care.