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Zorluk: OrtaData Collection Techniques

A practical nurse (PN) is observing a 74-year-old client admitted two days ago with bacterial pneumonia. During the morning rounds, the PN notes that the client, who was fully oriented the previous evening, is now restless, picking at the bed sheets, and unable to state their current location. Which data collection action should the PN prioritize next?

  1. A
    Review the client's admission history for a preexisting diagnosis of dementia.
  2. Obtain a current set of vital signs including a pulse oximetry reading.Cevap
  3. C
    Use a standardized behavioral pain scale to evaluate if the restlessness is caused by physical discomfort.
  4. D
    Perform a comprehensive neurological assessment to determine the specific etiology of the cognitive decline.

Cevap

Obtain a current set of vital signs including a pulse oximetry reading.
The correct answer emphasizes physiological prioritization and appropriate scope of practice. Sudden onset of restlessness and confusion in an older adult with a respiratory infection strongly suggests acute hypoxia. The PN must immediately prioritize focused data collection by obtaining vital signs and an oxygen saturation reading (addressing Airway and Breathing) to gather objective information before reporting the change in condition to the registered nurse.

Adım Adım Çözüm

1
Identify the acute change in the client's cognitive and behavioral status.
The client has rapidly transitioned from being fully oriented to being restless and confused.
Recognizing a sudden deviation from the established baseline is the critical first step in determining the urgency of the situation.
2
Correlate the new signs with the client's primary diagnosis and risk factors.
The client has bacterial pneumonia, which places them at a high risk for impaired gas exchange.
Restlessness and acute confusion are frequently the earliest physiological indicators of cerebral hypoxia, especially in older adults.
3
Select the appropriate and prioritized data collection technique within the PN scope of practice.
Checking pulse oximetry and completing a focused vital sign check.
This action immediately evaluates the ABCs (Airway, Breathing, Circulation) and gathers objective data to promptly report to the registered nurse.

Anahtar Kavram

Prioritizing focused data collection for oxygenation and vital signs when acute confusion occurs
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Konular

Data Collection Techniques

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