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Difficulty: EasyPhysiological Adaptation

An 85-year-old client is admitted with pneumonia and is receiving intravenous antibiotics. While making bedside rounds, the practical nurse discovers the client is suddenly agitated, attempting to climb out of bed, and breathing at a rate of 28 breaths per minute. Which action should the practical nurse take first?

  1. Measure the client's oxygen saturation and current vital signs.Answer
  2. B
    Guide the client back into bed and dim the lights to calm their dementia.
  3. C
    Apply physical safety devices to prevent the client from leaving the bed.
  4. D
    Perform a comprehensive pain assessment using a standardized scale.

Answer

Measure the client's oxygen saturation and current vital signs.
Sudden onset of agitation and confusion, especially when accompanied by a high respiratory rate, is a classic presentation of hypoxia in older adults. The correct immediate response is to gather focused, objective data regarding the client's respiratory status (oxygen saturation and vital signs) to identify the severity of the physiological compromise.

Step-by-Step Solution

1
Recognize the clinical cues.
The client is demonstrating sudden agitation, restlessness, and tachypnea (28 breaths per minute).
Identifying abnormal physiological findings is the first step in clinical judgment.
2
Prioritize the cues using the ABC framework.
Tachypnea points directly to a potential breathing or oxygenation issue, which takes priority over behavioral or pain concerns.
Airway, Breathing, and Circulation are the most critical physiological needs.
3
Determine the appropriate initial nursing action.
The nurse must collect focused objective data (oxygen saturation and vital signs) to report to the registered nurse for immediate intervention.
Sudden confusion is often an early sign of hypoxia in older adults, requiring prompt physiological assessment rather than environmental modifications.

Key Concept

Prioritizing Physiological Assessment in Acute Changes
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Topics

Physiological Adaptation

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