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Difficulty: MediumPhysiological Adaptation

An 80-year-old client is recovering on the surgical unit two days after a colon resection. During a routine check, the practical nurse (PN) notes the client is restless, repeatedly attempting to remove their intravenous (IV) line, and has difficulty focusing on questions. The client's current vital signs are: heart rate 114 bpm, blood pressure 104/62 mm Hg (baseline 138/76 mm Hg), and respiratory rate 22 breaths/minute. Which action should the PN take first?

  1. Notify the registered nurse (RN) immediately regarding the changes in vital signs and mental statusAnswer
  2. B
    Reorient the client to the surroundings and dim the room lights to reduce agitation
  3. C
    Ask the client to rate their surgical site pain and prepare to administer prescribed analgesics
  4. D
    Document the findings and plan to reassess the client's vital signs in one hour

Answer

Notify the registered nurse (RN) immediately regarding the changes in vital signs and mental status.
The client is displaying a classic triad of early shock or physiological decompensation: altered mental status (restlessness/confusion), tachycardia, and hypotension relative to baseline. In the practical nursing scope of practice, the recognition of an acute, potentially life-threatening change in client condition requires immediate escalation to the registered nurse or healthcare provider to prevent further deterioration.

Step-by-Step Solution

1
Analyze the client's vital signs and compare them to the baseline.
The heart rate is elevated (114 bpm) and the blood pressure is notably decreased (104/62 mm Hg) compared to the client's baseline (138/76 mm Hg), indicating potential circulatory compromise or shock.
Identifying trends and deviations from baseline is critical for recognizing early physiological deterioration.
2
Evaluate the new-onset behavioral changes in the context of the physical assessment.
The restlessness, pulling at lines, and inability to focus, when combined with the abnormal vital signs, suggest decreased cerebral perfusion (hypoxia or shock), not just typical delirium.
Altered mental status is often the earliest sign of impaired oxygenation or circulation in older adults.
3
Determine the priority action within the practical nurse (PN) scope of practice.
The PN must recognize the acute physiological instability and immediately escalate the findings to the RN.
When a client exhibits signs of acute decompensation, the immediate priority is to collaborate with the RN/provider to initiate life-saving interventions.

Key Concept

Recognizing Early Signs of Shock and Acute Deterioration
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Topics

Physiological Adaptation

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