A practical nurse (PN) at an urgent care clinic is collecting data from a young adult client who reports severe, continuous vomiting and abdominal pain for the past two days. The client states, 'I smoke cannabis every day, and the only thing that temporarily stops the nausea is taking a really hot shower.' The PN obtains the following vital signs: heart rate 118/min, blood pressure 92/58 mm Hg, and respiratory rate 20/min. Which action should the PN take first?
- Report the vital signs to the supervising registered nurse or healthcare provider immediately.Answer
- BAsk the client why they continue to use cannabis when it causes severe gastrointestinal discomfort.
- CDocument the vital signs as expected anxiety-related changes and continue the routine health history.
- DAccept a verbal prescription to independently administer an intravenous (IV) push antiemetic medication.
Answer
The correct action is to immediately report the vital signs to the supervising registered nurse or healthcare provider, as the client is showing early signs of hypovolemic shock due to severe dehydration.
The client's history of daily cannabis use, severe vomiting, and relief from hot showers strongly indicates cannabinoid hyperemesis syndrome. The vital signs reveal tachycardia and hypotension, which are early physiological signs of hypovolemic shock secondary to severe dehydration. Within the practical nurse scope of practice, recognizing and immediately reporting critical physiological deterioration to the registered nurse or healthcare provider is the highest priority.
Step-by-Step Solution
Key Concept
Cannabinoid hyperemesis syndrome can lead to severe dehydration and hypovolemic shock, requiring prompt recognition of abnormal vital signs and immediate escalation within the practical nurse scope of practice.