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Difficulty: MediumPhysiological Adaptation

While observing an 82-year-old client admitted 12 hours ago with severe diarrhea and vomiting, the practical nurse (PN) notes several clinical findings. Which of the following data points strongly suggest the client is developing hypovolemic shock and warrant immediate notification of the registered nurse (RN)? Select all that apply.

  1. New-onset restlessness and repeated attempts to remove the intravenous catheterAnswer
  2. A resting heart rate that has steadily climbed from 86 to 124 beats per minuteAnswer
  3. A total urine output of 45 mL accumulated over the past three hoursAnswer
  4. D
    Verbalization of dull, intermittent abdominal cramping
  5. E
    An oral temperature reading of 37.6°C (99.7°F)
  6. F
    Inability to recall the name of the admitting healthcare provider while fully oriented to person and place

Answer

The findings that indicate acute physiological deterioration and early hypovolemic shock are the new-onset restlessness, the climbing heart rate, and the significantly low urine output.
In a client experiencing severe fluid loss, hypovolemia can rapidly progress to shock. The body compensates for the decreased blood volume by increasing the heart rate to maintain cardiac output. As blood flow to vital organs diminishes, the client exhibits signs of cerebral hypoxia (restlessness and agitation) and decreased renal perfusion (oliguria, defined as less than 30 mL/hr). Recognizing this cluster of systemic signs is essential for prompt intervention.

Step-by-Step Solution

1
Identify the client's primary risk factor based on the admission diagnosis.
The client has severe gastroenteritis, which places them at high risk for fluid volume deficit and hypovolemic shock.
Understanding the baseline risk directs the focus toward signs of perfusion and hydration status.
2
Analyze each assessment finding to differentiate between expected symptoms and signs of systemic deterioration.
Abdominal cramping, slight memory gaps, and a low-grade temperature are expected or stable findings. Restlessness, tachycardia, and oliguria represent acute systemic changes.
Systemic complications like shock present with compensatory mechanisms (such as tachycardia) and signs of decreased end-organ perfusion.
3
Prioritize the findings that indicate a threat to circulation and airway/breathing (ABCs).
The increasing heart rate, very low urine output, and acute neurological changes confirm compromised circulation.
Immediate escalation to the RN is required when airway, breathing, or circulation is compromised.

Key Concept

Recognition of early hypovolemic shock and inadequate tissue perfusion
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Topics

Physiological Adaptation

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