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Difficulty: MediumPhysiological Adaptation

A 79-year-old client on a medical-surgical unit is undergoing treatment for a complicated urinary tract infection with intravenous antibiotics. During the night, the client, whose baseline mental status is alert and oriented, becomes highly agitated, attempts to climb out of bed, and pulls at the intravenous line. The practical nurse obtains the following vital signs: temperature 97.2°F (36.2°C), heart rate 118 beats/minute, blood pressure 94/52 mm Hg, and respiratory rate 24 breaths/minute. Which action should the practical nurse take first?

  1. Remain with the client and immediately report the vital signs and behavior changes to the registered nurse.Answer
  2. B
    Apply a protective wrap to the intravenous site to ensure the antibiotic infusion is not interrupted.
  3. C
    Document the behavior in the medical record as expected nighttime disorientation common in older adults.
  4. D
    Continue routine monitoring and plan to check vital signs again in four hours since the client is afebrile.

Answer

The priority action is to remain with the client and immediately report the vital signs and behavior changes to the registered nurse.
The correct answer addresses the immediate need for escalation when a client shows signs of acute physiological deterioration. The combination of sudden agitation, tachycardia, tachypnea, and hypotension in a client with a severe infection points directly to early septic shock. The practical nurse correctly identifies the emergency and immediately reports to the registered nurse while keeping the client safe.

Step-by-Step Solution

1
Analyze the client's new onset of symptoms.
The client has suddenly developed agitation and confusion, deviating from their alert baseline.
Sudden changes in mental status often indicate an acute physiological problem, such as poor cerebral perfusion, not a psychological one.
2
Evaluate the current vital signs in the context of the client's diagnosis.
Heart rate (118 bpm) is elevated, respiratory rate (24 breaths/min) is elevated, and blood pressure (94/52 mm Hg) is low.
These vital signs suggest circulatory compromise and inadequate tissue perfusion, which are early signs of septic shock associated with the urinary tract infection.
3
Determine the priority nursing action within the practical nurse scope of practice.
The practical nurse must immediately notify the registered nurse to escalate care while ensuring client safety.
Acute physiological deterioration requires immediate assessment and medical intervention beyond the practical nurse's independent scope.

Key Concept

Recognizing early signs of shock and prioritizing acute physiological changes over secondary equipment issues or assumptions about aging.
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Topics

Physiological Adaptation

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