Examkin

Question

Difficulty: MediumPhysiological Adaptation

Following the morning handoff report, a practical nurse (PN) begins data collection for a group of assigned clients. Which client findings represent acute physiological deterioration and require immediate intervention? Select all that apply.

  1. A client with a deep vein thrombosis who suddenly develops a cough and rapid breathing.Answer
  2. A client who is 2 hours post-appendectomy and exhibits a steady heart rate increase from 80 to 115 beats per minute.Answer
  3. A client receiving intravenous insulin whose skin becomes pale, cold, and clammy while becoming highly agitated.Answer
  4. D
    A client with a closed tibia fracture who is crying and urgently requesting pain medication.
  5. E
    An older adult client with advanced dementia who is completely unable to state their current location.
  6. F
    A client who is 24 hours postpartum and has saturated one perineal pad over the past 4 hours.

Answer

The correct findings indicating acute physiological deterioration are the client with a deep vein thrombosis developing a cough and rapid breathing, the post-appendectomy client with a rising heart rate, and the client on insulin exhibiting pale, clammy skin with agitation.
The correct findings all represent acute, life-threatening physiological changes. Sudden respiratory distress in a DVT client suggests a pulmonary embolism. A rising heart rate post-surgery is a classic early sign of internal bleeding and shock. Agitation with cold, clammy skin during insulin therapy indicates profound hypoglycemia. All three require immediate nursing intervention.

Step-by-Step Solution

1
Evaluate the client with deep vein thrombosis (DVT) for airway and breathing compromise.
The sudden onset of a cough and rapid breathing indicates a potential pulmonary embolism.
DVT clots can dislodge and travel to the lungs, creating a severe, life-threatening respiratory emergency.
2
Evaluate the post-appendectomy client and the client receiving insulin for systemic instability.
The rising heart rate indicates early hypovolemic shock, and pale, clammy skin with agitation indicates severe hypoglycemia.
Both represent acute, life-threatening circulatory and metabolic changes that demand urgent medical treatment.
3
Evaluate the remaining clients to differentiate acute deterioration from expected or non-emergent findings.
The clients with the tibia fracture, advanced dementia, and postpartum status have expected or non-life-threatening findings.
Expected pain, baseline cognitive disorientation, and normal lochia flow do not take precedence over ABC emergencies.

Key Concept

Prioritization of Acute Physiological Deterioration
Rate this question

Topics

Physiological Adaptation

More questions from this topic