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Zorluk: OrtaPhysiological Adaptation

A 79-year-old client is admitted to the medical unit for treatment of a severe urinary tract infection. Upon entering the room, the practical nurse (PN) finds the client highly agitated, disoriented to place, and pulling at their intravenous tubing. Current vital signs reveal a temperature of 101.4°F (38.5°C), heart rate of 115 beats/min, respiratory rate of 26 breaths/min, and blood pressure of 92/54 mmHg (admission blood pressure was 130/76 mmHg). Which action should the PN take first?

  1. Immediately report the clinical findings to the supervising registered nurse (RN) for further evaluation.Cevap
  2. B
    Note the acute confusion in the electronic health record as a normal age-related response to hospitalization.
  3. C
    Give a PRN oral sedative to safely manage the sudden agitation and prevent a potential fall.
  4. D
    Proceed with the standard plan of care, as these mild vital sign fluctuations are anticipated with an infection.

Cevap

The practical nurse should immediately report the changes in vital signs and mental status to the registered nurse.
The correct action identifies that the client is exhibiting classic signs of systemic inflammatory response and potential septic shock (hypotension, tachycardia, tachypnea, and fever) combined with altered mental status. In the practical nursing role, recognizing this physiological instability requires immediate escalation to the RN or provider for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's current clinical presentation against their baseline.
The client exhibits new-onset agitation, disorientation, tachycardia (115 beats/min), tachypnea (26 breaths/min), and a substantial drop in blood pressure (92/54 mmHg).
Identifying abnormal findings and vital sign trends is the first step in recognizing physiological deterioration.
2
Correlate the assessment data with the client's primary diagnosis.
The combination of a known infection with fever, hypotension, and altered mentation points strongly toward sepsis or early septic shock.
Understanding the pathophysiology of the condition allows the nurse to anticipate severe complications.
3
Determine the priority nursing action based on the PN scope of practice.
The PN must immediately escalate these critical findings to the RN or provider.
Acute hemodynamic instability requires rapid medical intervention (such as fluid resuscitation) and RN-level assessment to stabilize the client's circulation.

Anahtar Kavram

Recognition of Sepsis and Septic Shock
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Konular

Physiological Adaptation

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