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Question

Difficulty: MediumPhysiological Adaptation

A nurse is caring for a 72-year-old client being treated for a complicated urinary tract infection. The client's partner states, "My spouse is usually very sharp, but today they are extremely drowsy and talking about things that do not make sense." Assessment reveals a temperature of 97.6°F (36.4°C), apical pulse of 109 bpm, respirations of 22 breaths/min, and blood pressure of 92/52 mm Hg. Based on these findings, which intervention is the priority?

  1. Communicate the assessment findings to the supervising registered nurse immediately.Answer
  2. B
    Assure the partner that acute confusion is an expected part of the aging process during hospitalization.
  3. C
    Document the vital signs in the client's chart and continue with routine rounding.
  4. D
    Administer the client's prescribed oral analgesic for flank pain to promote comfort.

Answer

Communicate the assessment findings to the supervising registered nurse immediately.
The client is exhibiting classic signs of early sepsis and impending septic shock, including altered mental status, tachycardia, and borderline hypotension. The priority action for the practical nurse is to immediately escalate these critical, life-threatening findings to the supervising registered nurse or provider for rapid medical intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a diagnosed infection and is now presenting with new-onset altered mental status, tachycardia (109 bpm), and hypotension (92/52 mm Hg).
Identifying acute changes from the baseline is essential to recognize impending complications.
2
Correlate the findings with potential physiological adaptations.
The combination of infection, altered mentation, and hemodynamic instability strongly suggests early sepsis and impending septic shock.
Sepsis causes systemic vasodilation, leading to dropped blood pressure, a compensatory increase in heart rate, and decreased cerebral perfusion causing confusion.
3
Determine the priority nursing action based on the PN scope of practice.
The PN must immediately escalate the critical findings to the RN or healthcare provider.
Medical emergencies require immediate collaborative intervention outside the independent scope of the practical nurse.

Key Concept

Recognition of Sepsis and Shock
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Topics

Physiological Adaptation

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