Examkin

Question

Difficulty: MediumPhysiological Adaptation

An 80-year-old client is admitted to the medical-surgical unit with melena and a suspected upper gastrointestinal bleed. The practical nurse (PN) observes that the client has become suddenly restless, is attempting to get out of bed, and states, 'I have to go to work now.' The client's resting apical pulse is 114 beats/minute. Which action should the PN take first?

  1. A
    Document the apical pulse and plan to reassess in one hour.
  2. B
    Reorient the client to the hospital environment and the current time.
  3. Obtain the client's blood pressure and oxygen saturation.Answer
  4. D
    Apply a bed alarm to ensure the client remains safely in bed.

Answer

Obtain the client's blood pressure and oxygen saturation.
Sudden restlessness, acute confusion, and tachycardia in a client with a suspected gastrointestinal bleed are early compensatory signs of hypovolemic shock and cerebral hypoxia. The practical nurse must prioritize physiological data collection (Circulation and Breathing) to confirm these findings and immediately report them to the registered nurse.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a history of GI bleeding, sudden onset of confusion, restlessness, and tachycardia.
Identifying all abnormal cues is the first step in clinical judgment.
2
Correlate the symptoms with potential complications.
These findings strongly suggest decreased cardiac output, hypovolemia, and resulting cerebral hypoxia.
Active bleeding reduces circulating volume, leading to compensatory tachycardia and decreased oxygen delivery to the brain.
3
Determine the immediate priority action for the practical nurse.
The PN must gather a complete set of vital signs, specifically blood pressure and oxygen saturation.
According to the ABCs (Airway, Breathing, Circulation) and the nursing process, acute physiological data collection takes precedence over secondary safety or behavioral interventions.

Key Concept

Early recognition of hypovolemic shock and prioritization of physiological data collection.
Rate this question

Topics

Physiological Adaptation

More questions from this topic