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Difficulty: MediumPhysiological Adaptation

A client recovering from severe pneumonia is receiving intravenous antibiotics and continuous supplemental oxygen. The practical nurse enters the room to find the previously oriented client highly agitated, struggling to sit up, and picking aimlessly at the bed linens. Which action should the practical nurse take initially?

  1. Obtain the client's oxygen saturation level and count the respiratory rate.Answer
  2. B
    Give the client a prescribed as-needed sedative to prevent self-injury.
  3. C
    Place bilateral soft restraints on the client's wrists to maintain equipment safety.
  4. D
    Record the onset of the client's confusion as an expected response to being hospitalized.

Answer

The nurse should prioritize obtaining the client's oxygen saturation level and counting the respiratory rate.
In a client with a respiratory infection, sudden restlessness, agitation, and acute confusion are classic early signs of hypoxia. Using the nursing process and prioritizing Airway, Breathing, and Circulation (ABCs), the practical nurse must first collect objective data regarding the client's respiratory status before implementing any other interventions. Treating the symptoms without investigating the cause could lead to severe physiological deterioration.

Step-by-Step Solution

1
Identify the client's sudden change in condition.
The client is exhibiting acute agitation, restlessness, and confusion.
Recognizing a change from baseline is the first step in the clinical judgment process.
2
Correlate the behavioral changes with the client's underlying diagnosis.
The client has severe pneumonia, making them highly susceptible to impaired gas exchange and hypoxia.
Restlessness and acute confusion are classic early neurological signs of inadequate oxygenation to the brain.
3
Determine the priority nursing action using the ABCs (Airway, Breathing, Circulation) framework.
The nurse must obtain objective data regarding the client's respiratory status (oxygen saturation and respiratory rate).
Before implementing any interventions such as medications or restraints, the nurse must assess the most life-threatening potential cause of the behavioral change.

Key Concept

Recognizing early signs of hypoxia (restlessness and confusion) and prioritizing objective respiratory data collection.
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Topics

Physiological Adaptation

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