Examkin

Question

Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client who was admitted 12 hours ago with a pelvic fracture following a fall. The client is currently restless, frequently shifting in bed, and repeatedly asking for something to drink. The most recent vital signs reveal a blood pressure of 114/82 mm Hg, a heart rate of 118 beats/minute, and a respiratory rate of 24 breaths/minute. The client's admission heart rate was 84 beats/minute. Which of the following actions should the nurse take first?

  1. Perform a focused assessment of peripheral perfusion and inspect for internal bleeding.Answer
  2. B
    Administer the prescribed as-needed intravenous opioid analgesic.
  3. C
    Provide a small cup of clear liquids to alleviate the client's thirst.
  4. D
    Instruct the client to take slow, deep breaths to decrease the heart rate.

Answer

The correct action is to perform a focused assessment of peripheral perfusion and inspect for internal bleeding.
The correct answer focuses on further assessing for internal bleeding because the client is exhibiting classic early signs of hypovolemic shock. Pelvic fractures are highly vascular and prone to significant retroperitoneal bleeding. The body compensates for early blood loss by activating the sympathetic nervous system, leading to tachycardia, tachypnea, restlessness (due to mild cerebral hypoxia), and thirst. The blood pressure often remains normal in the early compensatory stage. The nurse must immediately perform a focused assessment of perfusion (such as capillary refill and skin temperature) and inspect for signs of bleeding before notifying the provider.

Step-by-Step Solution

1
Analyze the clinical cues presented by the client.
The client has a pelvic fracture, increasing tachycardia (84 to 118 beats/minute), tachypnea, restlessness, and intense thirst.
Identifying abnormal trends in vital signs and behavior is the first step in clinical judgment.
2
Correlate the cues to the underlying pathophysiology.
Pelvic fractures carry a high risk of massive internal hemorrhage. The identified cues are classic early compensatory signs of hypovolemic shock, even though the blood pressure remains within a normal range.
Understanding how the body compensates for blood loss allows the nurse to anticipate complications before severe hypotension occurs.
3
Determine the priority nursing action based on the assessment.
Before notifying the healthcare provider or implementing interventions, the nurse must gather targeted assessment data regarding tissue perfusion and potential bleeding.
The nursing process dictates that assessment must occur before intervention when a new, potentially life-threatening complication is suspected.

Key Concept

Early recognition of hypovolemic shock in high-risk trauma clients
Rate this question

Topics

Physiological Adaptation

More questions from this topic