An older adult client is hospitalized for observation following a mechanical fall that caused blunt abdominal trauma. During the night shift, the nurse notes that the client has become restless and mildly confused about their current location. Vital signs demonstrate a heart rate of 114 beats per minute, a blood pressure of 102/74 mm Hg, and a respiratory rate of 22 breaths per minute. The client's peripheral pulses are weak and extremities are cool. Which action should the nurse take first?
- AImplement advanced fall precautions and gently reorient the client to the hospital room.
- BAdminister the prescribed as-needed analgesic, anticipating that the restlessness is caused by underlying pain.
- Palpate the abdomen for firmness or distention and notify the charge nurse immediately.Answer
- DRecord the current vital signs and maintain routine monitoring as the blood pressure remains adequate.
Answer
The nurse should immediately assess the abdomen for signs of internal bleeding (firmness or distention) and notify the charge nurse.
The correct answer identifies that the client is exhibiting early signs of compensated hypovolemic shock due to internal bleeding. The combination of tachycardia, tachypnea, cool extremities, weak pulses, and new-onset confusion in a trauma client are critical indicators of decreased perfusion. The practical nurse must immediately collect targeted data regarding the abdomen and escalate these findings to the charge nurse for prompt medical intervention.
Step-by-Step Solution
Key Concept
Recognizing Early Compensated Shock