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Difficulty: MediumPhysiological Adaptation

Following a shift handoff on a medical-surgical unit, a practical nurse evaluates a client who was admitted for gastrointestinal bleeding 24 hours ago. The client's family member states that the client is unusually restless and seems disoriented this morning. The electronic health record shows a current heart rate of 114 bpm and a blood pressure of 98/60 mm Hg, compared to admission vital signs of 84 bpm and 134/78 mm Hg. Which action should the practical nurse take first?

  1. Report the change in mental status and vital signs to the registered nurse immediately.Answer
  2. B
    Reassure the family member that temporary disorientation is a normal reaction to hospitalization.
  3. C
    Document the vital signs in the chart and plan to recheck them during the next scheduled rounds.
  4. D
    Dim the room lights and close the door to provide a low-stimulation environment.

Answer

Report the change in mental status and vital signs to the registered nurse immediately.
The client is exhibiting early signs of hypovolemic shock (tachycardia, hypotension) and inadequate cerebral perfusion (restlessness, disorientation) stemming from the gastrointestinal bleeding. Within the practical nurse's scope of practice, recognizing acute physiological instability requires immediately notifying the registered nurse or provider so that rapid life-saving interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital sign trends.
The client has a new onset of restlessness, disorientation, tachycardia (114 bpm), and a decrease in blood pressure (98/60 mm Hg) compared to baseline.
Identifying deviations from baseline is critical for recognizing early physiological decompensation.
2
Correlate the findings with the client's admission diagnosis.
The symptoms indicate potential hypovolemic shock and inadequate cerebral perfusion due to active or worsening gastrointestinal bleeding.
Connecting symptoms to the underlying disease process determines the urgency of the situation.
3
Determine the most appropriate intervention within the practical nurse's scope of practice.
The immediate priority is to notify the registered nurse.
Acute, unstable changes require escalation for advanced assessment, fluid resuscitation, and potential medical intervention.

Key Concept

Early Recognition of Hypovolemic Shock
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Topics

Physiological Adaptation

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