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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) provides care for a 75-year-old resident in a skilled nursing facility who is receiving oral antibiotics for a lower urinary tract infection. During the afternoon shift, the PN discovers the resident is unusually restless, picking at their clothing, and breathing at a rate of 26 breaths/min. Which actions should the PN prioritize? Select all that apply.

  1. Measure the resident's blood pressure, heart rate, and peripheral oxygenation.Answer
  2. Evaluate the resident's capillary refill time and extremity skin temperature.Answer
  3. Contact the facility charge nurse to report the sudden change in condition.Answer
  4. D
    Chart the behavioral changes as expected sundown syndrome due to advanced age.
  5. E
    Administer the prescribed as-needed pain medication for possible dysuria.
  6. F
    Defer further hemodynamic data collection until the next scheduled shift assessment.

Answer

The correct actions involve prioritizing Airway, Breathing, and Circulation (ABC) data collection and escalating the findings. The PN should measure blood pressure, heart rate, and oxygenation, evaluate capillary refill and skin temperature, and immediately contact the charge nurse.
In an older adult with a localized infection, new-onset restlessness, confusion, and tachypnea are early warning signs of physiological decompensation, such as sepsis or hypoxia. The practical nurse must prioritize data collection related to Airway, Breathing, and Circulation (ABCs) by measuring oxygen saturation, blood pressure, heart rate, and peripheral perfusion (capillary refill, skin temperature). Because these findings suggest a critical shift in the client's status, immediate escalation to the supervising nurse is required to initiate prompt medical intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The new onset of restlessness and tachypnea (26 breaths/min) in a client with an active infection points toward systemic physiological compromise, such as early sepsis or hypoxia.
Recognizing acute changes from baseline is the foundation of clinical judgment and physiological adaptation.
2
Prioritize nursing interventions using the ABC framework.
Collecting comprehensive circulatory and respiratory data (blood pressure, oxygenation, capillary refill) takes precedence over routine comfort care.
Rapid identification of hemodynamic instability is essential for client survival and dictates immediate priorities.
3
Determine the appropriate scope of practice and next steps.
The PN must report these critical findings to the supervising registered nurse (RN) or provider.
Systemic physiological decompensation requires RN-level assessment and rapid provider-level medical orders.

Key Concept

Early Recognition of Systemic Infection and Shock in Older Adults
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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