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Zorluk: OrtaPhysiological Adaptation

While observing a 75-year-old client admitted earlier today with a closed pelvic fracture, the practical nurse notes the client is newly restless, mildly confused, and repeatedly asking for a drink. The client's current vital signs reveal a blood pressure of 102/66 mm Hg, a heart rate of 108 beats/min, and a respiratory rate of 22 breaths/min. Which of the following actions is the priority for the practical nurse?

  1. Report the client's vital signs and behavioral changes to the registered nurse immediatelyCevap
  2. B
    Reassure the client's family that mild confusion is a typical reaction to an unfamiliar hospital environment
  3. C
    Administer the prescribed as-needed pain medication to help manage the client's restlessness
  4. D
    Document the data in the electronic health record and recheck vital signs in one hour

Cevap

Report the client's vital signs and behavioral changes to the registered nurse immediately.
The correct action is to report the findings because the client is exhibiting early signs of hypovolemic shock (restlessness, confusion, thirst, tachycardia, and borderline hypotension), a life-threatening complication of pelvic fractures. The practical nurse must prioritize Circulation (ABCs) and immediately escalate these findings to the registered nurse for prompt intervention.

Adım Adım Çözüm

1
Analyze the client's current clinical presentation and vital signs.
The client is restless, confused, thirsty, and has borderline tachycardia (108 beats/min) and lower-end blood pressure (102/66 mm Hg).
Identifying abnormal clinical data is the first step in clinical judgment.
2
Connect the symptoms to the client's primary diagnosis of a pelvic fracture.
Pelvic fractures carry a high risk for massive internal retroperitoneal hemorrhage.
Understanding the complications associated with the diagnosis guides the interpretation of the symptoms.
3
Prioritize the required intervention based on the ABCs (Airway, Breathing, Circulation) and scope of practice.
The practical nurse identifies a Circulation emergency and must immediately escalate the findings.
Early hypovolemic shock is a medical emergency that requires rapid RN and provider intervention.

Anahtar Kavram

Early Recognition of Hypovolemic Shock
Tahmini Süre:1m 30s
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Physiological Adaptation

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