Examkin

Question

Difficulty: EasyPhysiological Adaptation

While assisting a 78-year-old client who was admitted with severe, acute diarrhea, the practical nurse (PN) notes that the client has become suddenly disoriented. The client's radial pulse is weak at 116 beats/min, and blood pressure is 88/54 mm Hg. Which action is the priority?

  1. Alert the registered nurse (RN) immediately about the changes in the client's condition.Answer
  2. B
    Remind the client of their location and minimize noise in the room.
  3. C
    Inquire about abdominal cramping and offer a warm blanket for comfort.
  4. D
    Record the measurements and plan to recheck the blood pressure in one hour.

Answer

The priority action is to immediately alert the registered nurse (RN) regarding the changes in the client's condition.
The client's presentation of severe diarrhea followed by sudden disorientation, tachycardia (116 beats/min), and hypotension (88/54 mm Hg) strongly indicates hypovolemic shock. Because the client is experiencing a life-threatening circulatory emergency that requires interventions outside the practical nurse's independent scope (such as administering intravenous fluids), the immediate priority is to notify the registered nurse so collaborative emergency care can begin.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a weak, rapid pulse (116 beats/min), low blood pressure (88/54 mm Hg), and new-onset disorientation.
Identifying abnormal data is the first step in clinical decision-making.
2
Correlate the findings with the client's history.
Severe diarrhea leads to significant fluid loss, which explains the tachycardia, hypotension, and poor cerebral perfusion (disorientation).
Connecting symptoms to the underlying cause helps identify hypovolemic shock.
3
Determine the priority intervention within the PN scope of practice.
The client requires immediate medical intervention (e.g., IV fluids) that is beyond independent PN practice, so the RN must be notified instantly.
Prioritization requires addressing circulation (ABC) emergencies immediately by escalating to the appropriate provider.

Key Concept

Hypovolemic Shock Recognition and Reporting
Rate this question

Topics

Physiological Adaptation

More questions from this topic