An -year-old client is hours post-operative following an exploratory laparotomy. The client, previously alert and cooperative, suddenly becomes profoundly restless, is disoriented to place, and repeatedly attempts to remove the intravenous catheter. Which of the following actions should the practical nurse take? Select all that apply.
- Measure the client's current oxygen saturation and assess the respiratory rate.Answer
- Obtain a complete set of vital signs to evaluate for potential hemodynamic instability.Answer
- Notify the registered nurse immediately regarding the acute change in the client's mental status.Answer
- DReassure the client's family that sudden confusion is a normal response to hospitalization in older adults.
- EAdminister the prescribed PRN dose of opioid analgesic to calm the client's severe agitation.
- FDocument the new heart rate of bpm as an expected anxiety response and reassess during the next shift.
Answer
The practical nurse should measure the client's oxygen saturation and respiratory rate, obtain a complete set of vital signs, and notify the registered nurse immediately.
Sudden restlessness and confusion in an older adult client are critical clinical cues that often indicate hypoxia, inadequate cerebral perfusion, or developing shock. The practical nurse must immediately prioritize Airway, Breathing, and Circulation (ABC) by gathering objective data (oxygen saturation and full vital signs) and escalating the acute mental status change to the registered nurse for urgent medical evaluation.
Step-by-Step Solution
Key Concept
In older adults, acute changes in mental status (such as sudden restlessness, agitation, or delirium) are frequently the earliest indicators of physiological decompensation, particularly hypoxia, infection, or hemodynamic instability. The nurse must prioritize ABC assessments over sedation.