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Difficulty: MediumPhysiological Adaptation

While conducting hourly rounds, a practical nurse (PN) responds to a call light from the spouse of an 84-year-old client being treated for pneumonia. The spouse reports the client has suddenly become disoriented and is trying to remove their intravenous line. The PN notes the client is extremely restless, with a heart rate of 110 bpm and a blood pressure of 98/60 mm Hg. Which action should the PN take first?

  1. Verify the client's oxygen saturation level and ensure airway patency.Answer
  2. B
    Reassure the spouse that this confusion is a standard response to illness in older adults.
  3. C
    Document the vital signs and plan to reassess the client's hemodynamic status in one hour.
  4. D
    Assess the client's pain intensity to determine if discomfort is causing the restlessness.

Answer

The priority action is to verify the client's oxygen saturation level and ensure airway patency.
Sudden onset of confusion, agitation, and restlessness in a client with pneumonia, accompanied by tachycardia and borderline hypotension, strongly suggests acute hypoxia or early shock. Using the ABC (Airway, Breathing, Circulation) framework, the priority is to immediately assess the client's oxygenation and airway status before intervening for other potential issues.

Step-by-Step Solution

1
Analyze the clinical cues presented by the client.
The client exhibits sudden disorientation, restlessness, tachycardia (110 bpm), and borderline hypotension (98/60 mm Hg).
Identifying abnormal findings is the first step in recognizing physiological decompensation.
2
Correlate the clinical cues with potential pathophysiological processes.
In an elderly client with pneumonia, these sudden changes strongly indicate potential respiratory compromise (hypoxia) or cardiovascular instability (early shock).
Understanding the underlying cause of the symptoms dictates the urgency and type of intervention required.
3
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
Evaluating the airway and oxygenation status takes precedence over secondary assessments or routine documentation.
Securing airway and breathing is the most critical initial action to prevent irreversible tissue damage or cardiac arrest.

Key Concept

Prioritization of Airway, Breathing, and Circulation (ABC) during acute physiological decompensation.
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Topics

Physiological Adaptation

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