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Difficulty: MediumPhysiological Adaptation

A 72-year-old client is admitted to the medical unit with acute gastroenteritis and frequent watery stools. During the afternoon shift, the practical nurse (PN) observes that the client is restless, has dry oral mucosa, and exhibits new mild confusion. The client's current vital signs are: blood pressure 102/64 mm Hg (admission baseline 130/80 mm Hg) and heart rate 114 beats/min (admission baseline 84 beats/min). Which action should the PN take first?

  1. A
    Continue to monitor and recheck the client's vital signs during the next scheduled interval.
  2. B
    Administer the prescribed as-needed (PRN) oral antidiarrheal medication to reduce fluid loss.
  3. Report the altered mental status and vital sign trends to the registered nurse (RN) immediately.Answer
  4. D
    Ask visiting family members if the client has a history of memory loss or dementia.

Answer

The correct action is to report the altered mental status and vital sign trends to the registered nurse (RN) immediately.
The correct action is to immediately escalate the findings to the RN. The client's history of fluid loss, combined with tachycardia, a significant drop in blood pressure from baseline, and new-onset confusion, strongly suggests early hypovolemic shock. The confusion is a critical indicator of inadequate cerebral perfusion, requiring emergent medical intervention beyond routine PN data collection.

Step-by-Step Solution

1
Analyze the client's presenting signs and symptoms.
The client has ongoing fluid loss, new-onset confusion, tachycardia, and a narrowing pulse pressure with hypotension compared to baseline.
Identifying abnormal cues is the first step in clinical judgment.
2
Connect the clinical findings to a physiological process.
The combination of these findings indicates severe dehydration progressing to early hypovolemic shock, leading to poor brain perfusion (causing confusion).
Understanding the pathophysiology of fluid volume deficit allows the nurse to determine the urgency of the situation.
3
Determine the priority nursing action based on the PN scope of practice.
Because the client is demonstrating acute physiological instability, the priority is to notify the RN to initiate rapid medical interventions (such as IV fluid resuscitation).
The PN must recognize life-threatening changes and escalate care to ensure the client receives immediate, appropriate interventions.

Key Concept

Early Recognition of Hypovolemic Shock
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Topics

Physiological Adaptation

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