Examkin

Question

Difficulty: Very hardPhysiological Adaptation

An 81-year-old client is receiving intravenous antibiotics for community-acquired pneumonia. The client's admission blood pressure was 142/86 mm Hg with a heart rate of 76/min. The client now appears agitated, is picking at the hospital gown, and repeatedly asks to go home. Current vital signs reveal a blood pressure of 106/64 mm Hg, heart rate of 112/min, and respirations of 26/min. Based on these findings, which intervention should the practical nurse execute first?

  1. Position the client upright to maximize lung expansion and promptly report the deteriorating status to the supervising registered nurse.Answer
  2. B
    Provide continuous verbal redirection and decrease ambient room lighting to minimize sensory overload.
  3. C
    Administer the prescribed as-needed anti-anxiety medication to prevent the client from attempting to ambulate unassisted.
  4. D
    Document the clinical observations in the health record and evaluate the hemodynamic status again during the next routine round.

Answer

Position the client upright to maximize lung expansion and promptly report the deteriorating status to the supervising registered nurse.
The client's shift from a hypertensive baseline to borderline hypotension, combined with tachycardia, tachypnea, and sudden agitation, strongly suggests physiological deterioration such as hypoxia or early sepsis. The most critical action is to support breathing by elevating the head of the bed and immediately escalating these findings so advanced interventions can be initiated.

Step-by-Step Solution

1
Analyze the baseline versus current vital signs.
The heart rate has increased from 76 to 112/min, blood pressure has dropped from 142/86 to 106/64 mm Hg, and respirations are elevated at 26/min.
Comparing current data to baseline is essential to identify trends indicating clinical deterioration.
2
Interpret the meaning of the behavioral changes in this clinical context.
Agitation and restlessness in a client with pneumonia and worsening hemodynamics indicate hypoxia or impending septic shock, rather than simple confusion or dementia.
Sudden mental status changes are often the earliest sign of compromised oxygenation and cerebral perfusion in older adults.
3
Determine the priority action within the practical nursing scope of practice.
The practical nurse must immediately support the client's breathing (elevating the head) and escalate the findings to the registered nurse.
Acute physiological decompensation requires immediate Airway, Breathing, and Circulation (ABC) support and advanced RN/provider intervention.

Key Concept

Early Recognition of Hypoxia and Shock
Rate this question

Topics

Physiological Adaptation

More questions from this topic