A -year-old resident at a rehabilitative care center is recovering from viral pneumonia. During evening rounds, the resident exhibits sudden, acute agitation, fails to recognize family members, and demonstrates a respiratory rate of breaths per minute. The current blood pressure is mmHg, a significant decrease from the morning baseline reading of mmHg, while the heart rate is bpm. Which of the following responses by the practical nurse demonstrate correct clinical prioritization? (Select all that apply.)
- Escalate the deteriorating hemodynamic status and altered mentation to the supervising registered nurse immediately.Answer
- Elevate the head of the bed, assess pulse oximetry, and prepare to administer supplemental oxygen.Answer
- Stay at the bedside to provide a safe environment and monitor for further respiratory compromise.Answer
- DAttribute the new-onset disorientation to sundowning syndrome and document the behavioral changes in the shift note.
- EDelay vital sign reporting, as the systolic blood pressure remains above mmHg and does not strictly indicate severe hypotension.
- FPrioritize administering a prescribed PRN oral analgesic to calm the resident before performing a full airway and breathing assessment.
Answer
The correct actions are to immediately escalate the condition to the registered nurse, elevate the head of the bed while preparing oxygen, and remain at the bedside to ensure safety.
The client is exhibiting clinical manifestations of acute hypoxia and early shock, characterized by tachypnea, tachycardia, relative hypotension, and acute confusion. The priority actions involve stabilizing the airway and breathing by elevating the head of the bed and assessing oxygenation, ensuring client safety by remaining at the bedside, and immediately escalating the critical change in condition to the registered nurse for urgent medical intervention.
Step-by-Step Solution
Key Concept
Recognition and Prioritization of Acute Hypoxia and Hemodynamic Instability