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Difficulty: HardPhysiological Adaptation

A practical nurse is caring for an 84-year-old client who was admitted with bacterial pneumonia. The client, who has been oriented and resting comfortably, suddenly becomes intensely restless, attempts to pull off the oxygen cannula, and cannot state their current location. Which actions should the nurse take immediately? Select all that apply.

  1. Assess the client's current oxygen saturation level using a pulse oximeter.Answer
  2. Elevate the head of the client's bed to a high-Fowler's position.Answer
  3. Obtain a complete set of vital signs including blood pressure and respiratory rate.Answer
  4. D
    Request a prescription for a mild sedative to manage the acute confusion.
  5. E
    Reorient the client to the room and gently dim the lights to promote sleep.
  6. F
    Assess the client for a distended bladder as a potential cause of the agitation.

Answer

The nurse should immediately assess oxygen saturation, elevate the head of the bed, and obtain a complete set of vital signs.
In a client with a respiratory infection, sudden restlessness, agitation, and confusion are cardinal early signs of hypoxia due to inadequate oxygen delivery to the brain. The practical nurse must immediately apply the ABC framework. Elevating the head of the bed optimizes chest expansion and gas exchange (Breathing). Measuring oxygen saturation and obtaining a full set of vital signs provide immediate, objective clinical data to quantify the respiratory deterioration and report findings to the RN or provider.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
An elderly client with pneumonia who suddenly develops severe restlessness and confusion.
Identifying the sudden change in neurological status provides the cue for physiological deterioration.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
The primary risk for a client with pneumonia is impaired gas exchange leading to hypoxia, which manifests early as central nervous system changes (restlessness and confusion).
Airway and Breathing take precedence over all other body systems and psychosocial needs.
3
Select interventions that directly assess and support respiratory function.
Checking oxygen saturation, elevating the head of the bed, and taking full vital signs address the immediate physiological threat.
These actions quickly identify the extent of respiratory compromise and optimize lung expansion without requiring a new provider prescription.

Key Concept

Early recognition of hypoxia through neurological changes (restlessness, confusion) and prioritizing ABCs in acute respiratory deterioration.
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Physiological Adaptation

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