Examkin

Soru

Zorluk: ZorPhysiological Adaptation

An older adult resident residing in an extended care facility is receiving intravenous antibiotic therapy for a severe soft tissue infection. The nursing assistant informs the practical nurse that the resident, who is usually alert and cooperative, is suddenly thrashing in bed and speaking incoherently. Upon evaluation, the nurse observes pale, diaphoretic skin with a heart rate of 118 beats per minute and a blood pressure of 92/54 mm Hg (baseline 136/80 mm Hg). Which intervention should the practical nurse implement immediately?

  1. A
    Provide frequent verbal orientation and dim the room lights to decrease agitation.
  2. Immediately alert the supervising nurse to the acute changes in the resident's condition.Cevap
  3. C
    Administer the prescribed as-needed pain medication to address the extreme restlessness.
  4. D
    Document the vital signs and plan to recheck them at the next routine interval.

Cevap

The practical nurse must immediately alert the supervising nurse to the acute changes in the resident's condition.
The correct action is to immediately escalate the findings to the supervising nurse. The resident's sudden confusion, diaphoresis, tachycardia, and significant drop in blood pressure in the presence of an active infection are hallmark signs of septic shock. This is a life-threatening physiological adaptation that requires rapid medical intervention, which must be initiated and overseen by a registered nurse or healthcare provider.

Adım Adım Çözüm

1
Analyze the resident's baseline data and current presentation.
The resident has a known infection and is suddenly confused, tachycardic (118 bpm), and hypotensive (92/54 mm Hg) compared to baseline.
Identifying acute deviations from baseline is essential for early recognition of life-threatening complications.
2
Correlate the clinical findings to potential pathophysiological processes.
The combination of a primary infection, new-onset altered mental status, increased heart rate, and decreased blood pressure strongly indicates early septic shock.
Septic shock causes systemic vasodilation, leading to hypotension and compensatory tachycardia, which subsequently decreases cerebral perfusion (causing confusion).
3
Determine the priority action within the practical nurse's scope of practice.
The highest priority is to escalate the findings to the supervising registered nurse or healthcare provider.
Septic shock is a medical emergency requiring urgent interventions outside the practical nursing scope, such as prescribing fluid boluses or ordering vasopressors.

Anahtar Kavram

Early Recognition of Shock and Priority Escalation
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Konular

Physiological Adaptation

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