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Difficulty: MediumPhysiological Adaptation

During afternoon rounds, a 71-year-old client hospitalized for bacterial pneumonia suddenly becomes restless, rubs their chest, and asks to speak with a deceased relative. The client's family states the client was completely lucid just an hour ago. Current vital signs reveal a heart rate of 114 beats per minute, a respiratory rate of 26 breaths per minute, and a blood pressure of 102/60 mm Hg. Which action should the nurse prioritize?

  1. Measure the client's oxygen saturation and evaluate respiratory effortAnswer
  2. B
    Frequently reorient the client to the hospital environment and dim the room lights
  3. C
    Document the borderline vital signs and plan to reassess them during the next shift
  4. D
    Administer the client's prescribed as-needed analgesic for chest discomfort

Answer

The correct action is to measure the client's oxygen saturation and evaluate respiratory effort.
The correct answer addresses the most critical physiological need first. In older adults, acute hypoxia often manifests as sudden confusion, agitation, or restlessness. Given the client's diagnosis of bacterial pneumonia and vital signs indicating tachycardia and tachypnea, assessing oxygenation status (Airway and Breathing) is the immediate priority.

Step-by-Step Solution

1
Analyze the client's baseline versus current presentation.
The client transitioned from lucid to suddenly restless and confused, alongside an increased heart rate (114) and respiratory rate (26).
Identifying sudden deviations from baseline helps determine if the situation is acute and life-threatening.
2
Apply prioritization frameworks (ABCs and Maslow's Hierarchy).
The most immediate life-threatening physiological need is adequate oxygenation (Airway and Breathing).
Infection (pneumonia) impairs gas exchange. Hypoxia often presents as new-onset restlessness, anxiety, and confusion in older adults.
3
Select the nursing action that directly addresses the highest priority need.
Assessing oxygenation status (pulse oximetry and respiratory effort) is the priority over addressing pain or reorienting the client.
Without adequate oxygenation, all other interventions will fail to stabilize the client.

Key Concept

Prioritizing ABCs and recognizing hypoxia-induced delirium in older adults.
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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