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Zorluk: KolayPhysiological Adaptation

An 82-year-old client is recovering on the medical-surgical unit two days after a bowel resection. Upon entering the room, the practical nurse observes that the client is newly restless, confused about their location, and has a heart rate of 118 beats per minute with a blood pressure of 92/56 mm Hg. The client also points to their abdomen and moans in pain. Which action should the practical nurse take first?

  1. Notify the registered nurse immediately regarding the mental status change and vital signs.Cevap
  2. B
    Administer the prescribed as-needed analgesic to treat the client's incisional pain.
  3. C
    Reorient the client to the room and document the confusion as an expected age-related change.
  4. D
    Continue to monitor the client and recheck the vital signs during the next scheduled hourly round.

Cevap

Notify the registered nurse immediately regarding the mental status change and vital signs.
The client is exhibiting signs of physiological instability, including tachycardia, hypotension, and new-onset confusion. These findings strongly suggest poor tissue perfusion or early shock. According to the ABCs (Airway, Breathing, Circulation) of prioritization, addressing acute circulatory compromise takes precedence over other interventions. The practical nurse must immediately report these acute changes to the registered nurse so prompt, life-saving medical treatment can be initiated.

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1
Analyze the client's new data, including new-onset confusion, tachycardia (118 bpm), and hypotension (92/56 mm Hg).
These findings are indicators of impaired physiological adaptation, specifically poor tissue perfusion or early shock.
Identifying acute, systemic changes in circulation and oxygenation is the critical first step in clinical judgment.
2
Prioritize the client's needs based on the Airway, Breathing, Circulation (ABC) framework.
The acute circulation and perfusion deficits take priority over the secondary issue of incisional pain.
Untreated shock or severe fluid loss can lead to rapid systemic deterioration and life-threatening complications.
3
Determine the appropriate intervention within the practical nursing scope of practice.
The practical nurse must immediately report these unstable findings to the registered nurse.
The registered nurse must perform a comprehensive assessment and collaborate with the healthcare provider to initiate acute medical treatment.

Anahtar Kavram

Prioritization of physiological instability and recognition of early shock.
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Konular

Physiological Adaptation

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