Examkin

Question

Difficulty: MediumPhysiological Adaptation

A nurse on a medical-surgical unit is evaluating the status of four assigned clients. Based on the provided clinical data, which client requires the nurse's immediate intervention?

  1. A client with a fractured pelvis whose blood pressure changed from 134/80 mm Hg to 110/88 mm Hg and heart rate increased from 78 to 108 beats/min.Answer
  2. B
    A client with severe chronic obstructive pulmonary disease (COPD) who has an arterial blood gas showing pH 7.36, PaCO2 56 mm Hg, and HCO3 31 mEq/L.
  3. C
    A client who had a lumbar puncture 3 hours ago, is resting in a supine position, and reports a mild headache.
  4. D
    An older adult client with advanced dementia who becomes increasingly agitated and confused as the evening approaches.

Answer

The client with a fractured pelvis whose blood pressure is narrowing and heart rate is increasing requires immediate intervention.
The client with the fractured pelvis is exhibiting early signs of hypovolemic (hemorrhagic) shock. The sympathetic nervous system attempts to compensate for blood loss by increasing the heart rate (tachycardia) and causing peripheral vasoconstriction, which raises the diastolic blood pressure and results in a narrowing pulse pressure. Because pelvic fractures can cause massive internal bleeding, this client is the most unstable and requires immediate life-saving assessment and intervention.

Step-by-Step Solution

1
Evaluate the clinical data for the client with the fractured pelvis.
The pulse pressure has narrowed from 54 mm Hg (134-80) to 22 mm Hg (110-88), and the heart rate has increased from 78 to 108 beats/min.
Pelvic fractures carry a high risk of concealed hemorrhage; these vital sign changes are the earliest indicators of compensatory shock.
2
Analyze the arterial blood gas values for the client with COPD.
The pH is normal (7.36), PaCO2 is elevated (56 mm Hg), and HCO3 is elevated (31 mEq/L).
This confirms fully compensated respiratory acidosis, a stable and expected baseline for chronic COPD, rather than an acute emergency.
3
Assess the post-procedure status of the client who had a lumbar puncture.
The client is experiencing a mild headache while lying supine.
This is an expected side effect, and the supine position is the appropriate prophylactic and therapeutic measure.
4
Review the behavioral changes in the client with dementia.
Increased confusion and agitation in the evening is identified as sundowning.
This is a chronic, expected manifestation of dementia rather than an acute, life-threatening physiological change.

Key Concept

Early recognition of shock through subtle vital sign trends (such as a narrowing pulse pressure and mild tachycardia) is a critical nursing priority over expected chronic or post-procedural findings.
Rate this question

Topics

Physiological Adaptation

More questions from this topic