Examkin

Soru

Zorluk: OrtaPhysiological Adaptation

The practical nurse is assigned to care for an older adult client diagnosed with severe community-acquired pneumonia. The client was alert and cooperative during the previous shift. Currently, the client is agitated, actively trying to climb out of bed, and giving disorganized answers to simple questions. Which action represents the most appropriate initial response by the nurse?

  1. A
    Verbally reorient the client to the hospital environment and current date.
  2. B
    Review the client's chart for an available as-needed antianxiety medication.
  3. C
    Apply a bed alarm and request an order for physical restraints.
  4. Obtain a pulse oximetry reading and assess the client's respiratory effort.Cevap

Cevap

Obtain a pulse oximetry reading and assess the client's respiratory effort.
Sudden onset of agitation and disorganized thinking in a client with a respiratory illness is a classic early sign of hypoxia. Using the ABC (Airway, Breathing, Circulation) framework, the nurse must first assess the client's respiratory status and tissue oxygenation before assuming the behavior is strictly psychological or age-related.

Adım Adım Çözüm

1
Identify the acute change in the client's condition.
The client has transitioned from alert and cooperative to agitated, confused, and unsafe.
Sudden mental status changes in older adults require immediate investigation to rule out life-threatening physiological causes.
2
Relate the client's underlying diagnosis to potential complications.
The client has severe pneumonia, which significantly impairs gas exchange and creates a high risk for hypoxia.
Hypoxia frequently manifests as restlessness, anxiety, agitation, and confusion, particularly before cyanosis or other late signs appear.
3
Prioritize nursing actions based on the ABC (Airway, Breathing, Circulation) framework.
Airway and breathing assessments must take precedence over psychosocial interventions or safety restraints.
Evaluating oxygen saturation and respiratory effort directly addresses the most likely and most critical physiological cause of the sudden agitation.

Anahtar Kavram

Prioritizing ABCs in Acute Confusion
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru