Examkin

Question

Difficulty: EasyPhysiological Adaptation

An older adult client with a history of heart failure suddenly becomes highly restless, confused, and demonstrates a respiratory rate of 30 breaths per minute. Which intervention should be prioritized immediately?

  1. Elevate the head of the bed to an upright sitting positionAnswer
  2. B
    Remind the client of the date, time, and location to address the confusion
  3. C
    Administer a prescribed mild analgesic to relieve potential discomfort causing the restlessness
  4. D
    Document the respiratory rate as a baseline variation and recheck in one hour

Answer

Elevate the head of the bed to an upright sitting position
Elevating the head of the bed expands lung capacity and improves oxygenation, addressing the immediate physiological need. Sudden restlessness and confusion combined with tachypnea are early signs of hypoxia, so stabilizing the airway and breathing takes priority over all other interventions.

Step-by-Step Solution

1
Analyze the client's presenting symptoms.
The combination of sudden restlessness, confusion, and tachypnea (30 breaths/min) indicates acute hypoxia and respiratory distress.
Identifying the physiological meaning of the symptoms determines the level of urgency.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework.
Breathing is significantly compromised, meaning respiratory support is the most critical need.
Life-threatening issues must be addressed before secondary symptoms like confusion or potential pain.
3
Select the most immediate and effective nursing intervention.
Placing the client in an upright sitting position facilitates immediate lung expansion.
Gravity pulls the diaphragm downward, increasing chest cavity volume and improving oxygenation.

Key Concept

Hypoxia Recognition and Airway Prioritization
Rate this question

Topics

Physiological Adaptation

More questions from this topic