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Difficulty: MediumPhysiological Adaptation

During morning rounds, a practical nurse (PN) evaluates an octogenarian client who has a known history of gastric ulcers. The client's baseline mental status is alert and oriented; however, the client is now displaying acute confusion and restlessness along with vague complaints of a stomach ache. The client's current heart rate is 114 beats/minute with a blood pressure of 102/64 mm Hg, representing a drop from a baseline blood pressure of 144/82 mm Hg. Which action should the PN take first?

  1. A
    Administer the prescribed as-needed analgesic for the client's abdominal discomfort.
  2. B
    Log the current vital signs in the electronic health record and plan to recheck them in 60 minutes.
  3. Report the assessment findings and change in mental status to the supervising registered nurse immediately.Answer
  4. D
    Institute fall precautions by reminding the client of their location and turning on the bed alarm.

Answer

Report the assessment findings and change in mental status to the supervising registered nurse immediately.
The correct action involves immediately escalating the client's condition to the registered nurse. The combination of acute confusion, restlessness, tachycardia, and a significant drop in baseline blood pressure in a client with a history of gastric ulcers strongly indicates early hemorrhagic shock from a gastrointestinal bleed. The practical nurse must recognize this acute physiological deterioration and immediately notify the registered nurse so that advanced assessment, provider notification, and life-saving fluid resuscitation can be initiated.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client has unexplained tachycardia, relative hypotension compared to baseline, acute confusion, and restlessness.
Identifying abnormal data and comparing it to the client's baseline is the first step in the clinical judgment process.
2
Correlate the assessment findings with the client's medical history.
The history of gastric ulcers combined with signs of decreased systemic perfusion strongly suggests active gastrointestinal bleeding.
Connecting the client's past medical history with acute symptoms helps identify the likely underlying complication.
3
Determine the priority nursing action based on the practical nurse (PN) scope of practice.
The PN must immediately escalate the unstable client's condition to the registered nurse for advanced intervention.
The client is experiencing a life-threatening emergency (hypovolemic shock) that requires immediate RN assessment and provider notification for fluid resuscitation.

Key Concept

Early Recognition of Hypovolemic Shock
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Topics

Physiological Adaptation

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