Examkin

Question

Difficulty: EasyPhysiological Adaptation

A practical nurse (PN) is caring for a 75-year-old client who was admitted with severe viral gastroenteritis. During morning care, the PN notes that the client is extremely lethargic and difficult to wake up. The client's heart rate is 116 beats per minute and blood pressure is 92/56 mm Hg. What is the priority action for the PN?

  1. Notify the registered nurse (RN) immediately about the changes in vital signs and mental status.Answer
  2. B
    Document the vital signs and plan to recheck them in four hours.
  3. C
    Assume the lethargy is a normal age-related response to hospitalization.
  4. D
    Focus on providing a warm blanket and a quiet environment for rest.

Answer

The correct action is to immediately notify the registered nurse (RN) about the abnormal vital signs and lethargy.
The client is exhibiting clear signs of hypovolemic shock due to fluid loss from severe gastroenteritis, including tachycardia, hypotension, and altered mental status. The practical nurse must recognize these critical changes as a failure of physiological adaptation and immediately escalate the findings to the registered nurse for prompt medical intervention.

Step-by-Step Solution

1
Analyze the client's vital signs and mental status.
The heart rate of 116 bpm and blood pressure of 92/56 mm Hg indicate hemodynamic instability. The extreme lethargy indicates decreased brain perfusion.
Recognizing deviations from normal physiological baselines is the first step in clinical judgment.
2
Identify the underlying physiological process.
The client has a history of severe gastroenteritis, making fluid volume deficit and hypovolemic shock the primary concern.
Connecting the symptoms to the admitting diagnosis helps determine the urgency of the situation.
3
Determine the appropriate nursing intervention within the PN scope of practice.
The PN must report these critical findings to the RN immediately.
Acute physiological decompensation requires rapid escalation to the RN or provider for advanced assessment and treatment orders.

Key Concept

Recognizing and Escalating Hypovolemic Shock
Rate this question

Topics

Physiological Adaptation

More questions from this topic