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Question

Difficulty: MediumPhysiological Adaptation

An older adult client with a history of mild dementia is receiving care for severe dehydration secondary to gastroenteritis. The client is usually cooperative but suddenly becomes extremely restless and begins pulling at their intravenous tubing. The practical nurse (PN) obtains a heart rate of 114 beats/min and a blood pressure of 94/56 mm Hg. What is the priority action for the PN?

  1. Immediately report the altered mental status and vital sign changes to the registered nurse (RN).Answer
  2. B
    Dim the room lights and frequently remind the client where they are.
  3. C
    Continue to monitor the client and repeat the vital sign measurements in one hour.
  4. D
    Give the client a PRN dose of medication for gastrointestinal discomfort.

Answer

The priority action is to immediately report the altered mental status and vital sign changes to the registered nurse (RN).
The client is demonstrating classic signs of early hypovolemic shock caused by dehydration: tachycardia, hypotension, and altered mental status (restlessness due to decreased cerebral perfusion). Recognizing these subtle but critical changes and immediately notifying the RN is the priority action within the PN scope of practice to facilitate life-saving interventions, such as an intravenous fluid bolus.

Step-by-Step Solution

1
Analyze the client's clinical presentation and recent history.
The client has a history of severe fluid loss (gastroenteritis) and is now showing acute restlessness, tachycardia (114 beats/min), and hypotension (94/56 mm Hg).
Understanding the complete clinical picture is the first step in recognizing physiological deterioration.
2
Differentiate between the client's baseline cognitive status and acute changes.
The acute restlessness and pulling at tubes represent a significant change from their baseline 'mild dementia' and cooperative nature.
Sudden mental status changes (delirium) often indicate an underlying physiological problem, such as poor cerebral perfusion or hypoxia.
3
Prioritize nursing actions based on the severity of the findings and the PN scope of practice.
The findings indicate impending hypovolemic shock, requiring immediate escalation of care to the RN for rapid medical intervention.
Under the PN scope of practice, acute hemodynamic instability is a life-threatening priority that must be immediately reported.

Key Concept

Early recognition of hypovolemic shock and acute delirium in older adults.
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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