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Zorluk: ZorPhysiological Adaptation

A practical nurse (PN) is evaluating a 79-year-old client admitted yesterday with an acute exacerbation of peptic ulcer disease. The client's spouse calls the PN to the room, stating the client suddenly seems highly disoriented and is attempting to get out of bed. The PN observes the client's skin is pale and cool to the touch. Current vital signs are: heart rate 108 beats/minute, respirations 22 breaths/minute, and blood pressure 104/66 mm Hg. The client's admission blood pressure was 142/84 mm Hg. Which action should the PN take FIRST?

  1. A
    Assist the client in transferring to a bedside commode to prevent a potential fall.
  2. B
    Reassure the spouse that acute confusion is a normal response for older adults in an unfamiliar hospital environment.
  3. Immediately report the clinical findings and vital signs to the registered nurse.Cevap
  4. D
    Proceed with administering the client's next scheduled dose of a prescribed intravenous proton pump inhibitor.

Cevap

The correct action is to immediately report the clinical findings and vital signs to the registered nurse.
The correct action prioritizes the immediate escalation of critical, life-threatening data. The client is exhibiting classic signs of early hypovolemic shock secondary to a suspected gastrointestinal bleed. The significant decrease in blood pressure from baseline, combined with tachycardia, pale/cool skin, and acute confusion (due to decreased cerebral perfusion), requires rapid intervention beyond the PN's independent scope of practice. The RN must be notified immediately to initiate collaborative emergency protocols.

Adım Adım Çözüm

1
Analyze the client's current assessment data.
The client has new-onset confusion, pale/cool skin, mild tachycardia (108 bpm), and a significant drop in blood pressure compared to baseline.
Identifying acute changes from baseline is the first step in clinical judgment.
2
Relate the findings to the client's diagnosis.
The client has peptic ulcer disease, placing them at high risk for acute gastrointestinal hemorrhage.
Connecting the history to the current presentation helps determine the underlying cause.
3
Synthesize the physiological cues.
The combination of subtle vital sign changes and altered mental status points to early hypovolemic (hemorrhagic) shock and decreased cerebral perfusion.
Recognizing shock early is critical for patient survival before irreversible damage occurs.
4
Determine the priority PN action.
The PN must immediately escalate the findings to the RN.
Hypovolemic shock is a medical emergency requiring rapid interventions (e.g., fluid resuscitation, blood transfusion) that require RN and provider collaboration.

Anahtar Kavram

Early Recognition of Hypovolemic Shock
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Konular

Physiological Adaptation

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