Following shift report on a progressive care unit, the registered nurse establishes the initial rounding order for assigned clients. Which client requires immediate evaluation?
- A client admitted with a heart failure exacerbation who is newly restless and has a blood pressure of 90/76 mm Hg.Answer
- BA client 3 days post-myocardial infarction who reports sharp chest pain that worsens with deep inspiration and improves when leaning forward.
- CA client with a deep vein thrombosis receiving a continuous intravenous heparin infusion who has an activated partial thromboplastin time (aPTT) of 75 seconds.
- DA client with chronic atrial fibrillation scheduled for a cardioversion who has an international normalized ratio (INR) of 2.6.
Answer
The client admitted with a heart failure exacerbation who is newly restless and has a blood pressure of 90/76 mm Hg requires immediate evaluation.
The correct answer describes a client exhibiting early signs of cardiogenic shock. New-onset restlessness is a highly sensitive early indicator of hypoxia and decreased cerebral perfusion. Furthermore, a blood pressure of 90/76 mm Hg reveals a severely narrowed pulse pressure of 14 mm Hg. A normal pulse pressure is typically 30 to 50 mm Hg; a significantly narrow pulse pressure in a heart failure client indicates the left ventricle is failing to generate adequate stroke volume. This client is highly unstable and requires immediate life-saving intervention.
Step-by-Step Solution
Key Concept
In prioritization, sudden neurological changes (restlessness) and vital sign trends indicating decreased cardiac output (narrowing pulse pressure) signal impending shock and demand immediate intervention.