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Difficulty: MediumPhysiological Adaptation

An emergency department nurse is caring for an older adult client who was brought from an assisted living facility with a suspected urinary tract infection. The client, who is typically alert and oriented, is currently restless and agitated. Vital signs reveal a temperature of 38.2°C (100.8°F), a heart rate of 118 beats/min, a respiratory rate of 24 breaths/min, and a blood pressure of 106/82 mm Hg. The client's blood pressure upon arrival one hour ago was 128/74 mm Hg. Which of the following actions should the nurse take first?

  1. Administer a prescribed isotonic intravenous fluid bolus.Answer
  2. B
    Obtain a 12-lead electrocardiogram to evaluate the elevated heart rate.
  3. C
    Administer a prescribed low-dose sedative to manage the client's acute agitation.
  4. D
    Document the findings and plan to reassess the vital signs in one hour.

Answer

The priority action is to administer a prescribed isotonic intravenous fluid bolus.
This client is exhibiting classic signs of early (compensatory) septic shock. The key clinical indicator is the rapidly narrowing pulse pressure (from 54 mm Hg upon arrival to 24 mm Hg currently). Combined with tachycardia, tachypnea, and new-onset agitation (a symptom of cerebral hypoxia), these findings demonstrate that the body is attempting to compensate for decreased systemic perfusion. The absolute priority is to restore intravascular volume and improve tissue perfusion by administering an isotonic intravenous fluid bolus.

Step-by-Step Solution

1
Analyze the trend in the client's vital signs and clinical presentation.
The client has developed a rapidly narrowing pulse pressure (from 54 to 24 mm Hg), tachycardia, tachypnea, and new-onset agitation.
Identifying acute changes from baseline helps the nurse recognize rapid physiological deterioration.
2
Correlate the clinical findings with the underlying pathology.
The combination of a suspected infection (UTI), fever, narrowing pulse pressure, tachycardia, and altered mental status points to early (compensatory) septic shock.
Agitation indicates decreased cerebral perfusion, while the vital sign changes reflect the body's sympathetic nervous system attempting to maintain cardiac output.
3
Determine the highest priority nursing intervention.
The most critical need is to restore circulating intravascular volume and tissue perfusion by administering isotonic intravenous fluids.
According to the ABCs and prioritization principles, circulatory collapse must be addressed immediately to prevent progression to uncompensated shock and multi-organ failure.

Key Concept

Recognition and initial management of early compensatory shock, characterized by a narrowing pulse pressure, tachycardia, and altered mental status.
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Topics

Physiological Adaptation

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