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Difficulty: MediumPhysiological Adaptation

A practical nurse is assessing an 8282-year-old client diagnosed with acute pyelonephritis who is receiving intravenous antibiotics. The client, who was previously oriented, suddenly exhibits marked restlessness and confusion. Vital signs reveal a blood pressure of 92/6092/60 mm Hg (baseline was 136/82136/82 mm Hg), a heart rate of 118118 beats/minute, and a respiratory rate of 2424 breaths/minute. Which action should the practical nurse implement first?

  1. A
    Reassess the client's vital signs in one hour to monitor for further hemodynamic changes.
  2. B
    Administer the client's prescribed as-needed analgesic to alleviate potential discomfort.
  3. Notify the registered nurse immediately to report the acute changes in condition.Answer
  4. D
    Initiate frequent reorientation and reassure the client, assuming the confusion is age-related.

Answer

The correct action is to notify the registered nurse immediately regarding the acute changes in the client's condition.
The correct answer identifies the need for immediate escalation. The client's presentation of a known infection accompanied by sudden confusion, a significant drop in blood pressure, and tachycardia indicates early septic shock. Within the practical nurse's scope of practice, recognizing these critical cues and immediately notifying the registered nurse is the highest priority to ensure the client receives life-saving interventions.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a severe infection and is exhibiting new-onset confusion, restlessness, significant hypotension (92/6092/60 mm Hg from a baseline of 136/82136/82 mm Hg), tachycardia (118118 beats/minute), and tachypnea.
Identifying abnormal assessment data is the first step in clinical reasoning.
2
Correlate the findings to potential complications.
The combination of infection, altered mental status, and deteriorating vital signs points strongly to systemic inflammatory response syndrome (SIRS) or early septic shock.
Recognizing patterns of physiological decompensation ensures timely intervention.
3
Determine the priority nursing action based on scope of practice.
The practical nurse must urgently escalate these critical findings to the registered nurse or provider for immediate medical intervention.
Initiating advanced shock management requires the RN and provider, making immediate communication the highest priority.

Key Concept

Early recognition of shock and acute physiological decompensation requires immediate escalation to the registered nurse.
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Topics

Physiological Adaptation

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