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Question

Difficulty: HardPhysiological Adaptation

While performing afternoon rounds at a skilled nursing facility, the practical nurse observes that a client currently being treated for a urinary tract infection is unusually lethargic and takes several seconds to answer simple questions. The client's baseline mental status is fully alert and oriented. Current vital signs reveal a temperature of 97.2°F (36.2°C), a heart rate of 108 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 94/56 mm Hg. What is the priority nursing action?

  1. A
    Provide additional warm blankets and reassess the client's vital signs in one hour.
  2. Immediately communicate the vital signs and altered mental status to the registered nurse.Answer
  3. C
    Assess the client for new-onset flank pain or suprapubic tenderness.
  4. D
    Document the lethargy as an expected response to the active infection and let the client rest.

Answer

Immediately communicate the vital signs and altered mental status to the registered nurse.
The client is demonstrating classic signs of clinical deterioration and impending septic shock, which include altered mental status, hypothermia (common in older adults with sepsis), tachycardia, tachypnea, and hypotension. The practical nurse's immediate priority is to recognize this life-threatening shift in physiological adaptation and escalate the findings to the registered nurse to facilitate prompt emergency treatment.

Step-by-Step Solution

1
Analyze the client's current vital signs and mental status against their baseline.
The client has a new onset of lethargy, hypothermia, tachycardia, tachypnea, and hypotension.
Identifying acute deviations from baseline is essential to recognize clinical deterioration.
2
Synthesize the data in the context of the current diagnosis (urinary tract infection).
The combination of infection and these specific vital sign changes indicates a systemic inflammatory response, pointing toward septic shock.
Sepsis can present atypically in older adults, often with hypothermia rather than fever, alongside cardiovascular compromise.
3
Determine the priority action within the practical nurse's scope of practice.
The priority is to escalate the critical findings to the registered nurse for immediate collaborative intervention.
Septic shock is a life-threatening emergency that requires rapid fluid resuscitation and intravenous antibiotics, necessitating immediate RN and provider involvement.

Key Concept

Recognition of Sepsis and Septic Shock
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Topics

Physiological Adaptation

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