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Difficulty: MediumPhysiological Adaptation

An older adult client with a history of congestive heart failure and chronic bronchitis is receiving inpatient care. The practical nurse observes that the client, who was alert and oriented two hours prior, has suddenly become highly agitated, is attempting to climb over the bed rails, and is unable to answer simple questions. Which of the following actions should the practical nurse prioritize?

  1. A
    Explain to the family that sudden confusion is an expected reaction to hospitalization for older adults.
  2. B
    Administer the prescribed as-needed analgesic to help relieve the client's severe agitation.
  3. Apply a pulse oximeter to evaluate the client's current oxygen saturation level.Answer
  4. D
    Place physical restraints on the client immediately to prevent a potential fall from the bed.

Answer

The practical nurse should prioritize applying a pulse oximeter to evaluate the client's current oxygen saturation level.
The correct action is to apply a pulse oximeter. In clinical practice, sudden onset of restlessness, agitation, or confusion—especially in a client with cardiopulmonary comorbidities—is one of the earliest signs of hypoxia. Using the ABC (Airway, Breathing, Circulation) framework, the nurse must prioritize assessing respiratory status before implementing any other interventions.

Step-by-Step Solution

1
Identify the acute change in the client's condition.
The client has transitioned from alert and oriented to highly agitated and confused within a short timeframe.
Recognizing a sudden change in mental status is the first step in identifying a physiological decompensation.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework to the client's symptoms and history.
The client has a history of congestive heart failure and chronic bronchitis, putting them at high risk for respiratory compromise.
In clients with cardiopulmonary disease, sudden restlessness and confusion are classic early indicators of hypoxia.
3
Select the intervention that addresses the highest priority physiological need.
Assessing oxygenation via pulse oximetry provides immediate data on the 'Breathing' component of the ABCs.
Before treating symptoms with medications or restraints, the underlying life-threatening cause must be investigated.

Key Concept

Prioritization of Airway and Breathing (ABCs) in Acute Decompensation
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Topics

Physiological Adaptation

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