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Difficulty: EasyPhysiological Adaptation

During morning rounds, a practical nurse evaluates a client admitted with a severe urinary tract infection. The client was fully oriented yesterday but is now highly agitated, picking at their clothing, and unable to recognize family members. Which action should the nurse take first?

  1. Measure the client's current vital signs and oxygen saturationAnswer
  2. B
    Inform the family that sudden confusion is a normal part of the aging process
  3. C
    Administer the client's prescribed as-needed medication for joint pain
  4. D
    Apply physical restraints to prevent the client from injuring themselves

Answer

Measure the client's current vital signs and oxygen saturation
The correct answer addresses the immediate need to evaluate physiological stability. An acute change in mental status, such as sudden agitation and disorientation, is a primary indicator of a severe physiological complication like hypoxia, hypoglycemia, or sepsis. The practical nurse must immediately gather objective data (vital signs and oxygen saturation) to identify the underlying physiological cause before notifying the registered nurse or provider.

Step-by-Step Solution

1
Analyze the clinical scenario
The client has experienced a sudden, acute change in mental status (agitation and disorientation) compared to their baseline.
Recognizing a sudden change in condition is the first step in clinical judgment.
2
Determine the potential underlying cause
Acute confusion (delirium) in a client with an infection often indicates systemic compromise, such as hypoxia, sepsis, or fluid imbalance.
Linking the symptom to potential physiological complications guides prioritization.
3
Select the highest priority nursing action
Obtaining vital signs and oxygen saturation must be done immediately.
According to the nursing process and ABC prioritization, objective physiological data must be collected first to ensure airway, breathing, and circulation are stable before implementing other interventions.

Key Concept

Early recognition of acute physiological deterioration requires immediate data collection (vital signs and oxygenation) before implementing secondary interventions.
Estimated Time:45s
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Topics

Physiological Adaptation

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