Examkin

Question

Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is collecting data on a 78-year-old client who is receiving intravenous antibiotics for a severe urinary tract infection. Which of the following assessment findings should the PN identify as early indicators of systemic decompensation and report to the registered nurse (RN) immediately? Select all that apply.

  1. A resting heart rate of 114 beats/min and a blood pressure of 96/58 mm HgAnswer
  2. New-onset restlessness and the client stating they are waiting for a trainAnswer
  3. A respiratory rate of 26 breaths/min with shallow chest expansionAnswer
  4. D
    The client reports a pain level of 4 on a 0 to 10 scale localized to the suprapubic area
  5. E
    The client's most recent void yielded 150 mL of cloudy, foul-smelling urine
  6. F
    The client's spouse reports the client has experienced gradual forgetfulness over the past two years

Answer

The correct findings are a resting heart rate of 114 beats/min with a blood pressure of 96/58 mm Hg, new-onset restlessness with confusion, and a respiratory rate of 26 breaths/min.
The correct options indicate acute systemic deterioration (sepsis), prioritizing Airway, Breathing, and Circulation (ABC) issues. Tachycardia with borderline hypotension suggests early shock. Tachypnea is a primary respiratory compensatory mechanism during systemic stress. Furthermore, older adults frequently exhibit acute confusion (delirium) as a primary sign of hypoxia or worsening infection.

Step-by-Step Solution

1
Analyze the client's current diagnosis and primary risk factors.
The older adult client has a severe urinary tract infection, placing them at high risk for the infection spreading systemically (sepsis).
Identifying the primary risk helps distinguish expected localized symptoms from emergent systemic complications.
2
Evaluate vital signs for Airway, Breathing, and Circulation (ABC) compromise.
A heart rate of 114 beats/min with borderline hypotension (96/58 mm Hg) and a respiratory rate of 26 breaths/min indicate physiological stress.
ABCs are the highest priority in acute care, and these borderline vital signs are classic early indicators of shock and respiratory decompensation.
3
Assess for acute neurological changes compared to baseline.
New-onset restlessness and confusion (delirium) are critical acute findings, distinguishing them from the chronic gradual forgetfulness reported by the spouse.
In older adults, acute mental status changes are often the first sign of hypoxia or systemic infection.
4
Compare emergent findings with expected localized symptoms.
Mild suprapubic pain and cloudy urine are localized, expected findings that do not require immediate emergency escalation.
Prioritization requires the nurse to address systemic physiological instability before expected, chronic, or local symptoms.

Key Concept

Physiological Adaptation: Recognizing Early Signs of Systemic Decompensation and Sepsis
Estimated Time:1m 30s
Rate this question

Topics

Physiological Adaptation

More questions from this topic