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Difficulty: HardPhysiological Adaptation

While performing morning rounds, a practical nurse evaluates a 71-year-old client admitted for severe melena secondary to peptic ulcer disease. The client, who was previously alert, is now acutely restless and disoriented. The client's heart rate is 124 bpm, blood pressure is 92/58 mm Hg (baseline 128/74 mm Hg), and respiratory rate is 24 breaths/min. Which action should the practical nurse take FIRST?

  1. Position the client supine with the legs elevated and immediately notify the registered nurseAnswer
  2. B
    Initiate delirium precautions by reorienting the client and minimizing environmental stimuli
  3. C
    Ask the client to rate their abdominal pain and prepare a prescribed analgesic
  4. D
    Record the current vital signs in the chart and plan to reassess the blood pressure in 30 minutes

Answer

The practical nurse should position the client supine with the legs elevated and immediately notify the registered nurse.
The client's presentation of melena, tachycardia, hypotension, and sudden restlessness is a classic triad for acute hypovolemic shock resulting from blood loss. The priority is to maintain circulation and perfusion to vital organs, specifically the brain and heart. Placing the client in a supine position with the legs elevated (modified Trendelenburg) uses gravity to increase venous return from the lower extremities. Because this is a medical emergency requiring rapid interventions beyond the practical nursing scope (such as IV fluid resuscitation or blood transfusions), immediately notifying the registered nurse is critical.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital sign trends.
The client has a history of melena (gastrointestinal bleeding) and now presents with tachycardia (124 bpm), hypotension (92/58 mm Hg), and acute mental status changes.
Identifying the pattern of symptoms helps determine if the client is experiencing a life-threatening complication.
2
Correlate the findings with physiological processes.
The combination of these signs strongly indicates hypovolemic shock resulting from acute blood loss. The brain is not receiving adequate perfusion, causing the sudden restlessness and disorientation.
Understanding the pathophysiology guides the selection of the most appropriate immediate intervention.
3
Apply the ABC (Airway, Breathing, Circulation) priority framework to select the best action.
Circulation is severely compromised. The nurse must support blood pressure and cerebral perfusion by elevating the legs and escalate the situation to the RN.
In emergent situations, interventions that support ABCs and escalate care take precedence over routine assessments or comfort measures.

Key Concept

Recognition and initial bedside management of hypovolemic shock
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Topics

Physiological Adaptation

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