Examkin

Soru

Zorluk: OrtaPhysiological Adaptation

A practical nurse (PN) is caring for a 72-year-old client who was admitted two days ago following a motor vehicle collision that resulted in a fractured pelvis. During the evening shift, the client becomes increasingly restless, begins pulling at the bed linens, and exhibits new-onset confusion regarding the current location. The client's vital signs are blood pressure 104/82 mm Hg, heart rate 114 beats per minute, and respiratory rate 24 breaths per minute. Which action should the PN take first?

  1. A
    Reorient the client to the hospital environment and ensure the room is well-lit.
  2. B
    Administer the prescribed as-needed analgesic to promote comfort and rest.
  3. Immediately report the change in mental status and vital signs to the registered nurse.Cevap
  4. D
    Document the current vital signs and plan to reevaluate them in two hours.

Cevap

Immediately report the change in mental status and vital signs to the registered nurse.
Pelvic fractures carry a significant risk for internal hemorrhage. The client's new-onset confusion, restlessness, tachycardia, tachypnea, and narrowing pulse pressure are early clinical indicators of hypovolemic shock resulting from decreased cerebral perfusion. The PN must prioritize client safety by immediately notifying the registered nurse so that rapid medical interventions can be initiated.

Adım Adım Çözüm

1
Analyze the client's current presentation and vital signs.
The client has a high-risk injury (pelvic fracture), new-onset confusion, restlessness, tachycardia (114 beats/min), tachypnea (24 breaths/min), and a narrow pulse pressure (104/82 mm Hg).
Identifying acute deviations from baseline is the first step in clinical judgment.
2
Correlate the assessment findings with potential physiological complications.
These systemic findings suggest a lack of oxygenated blood reaching the brain and compensatory mechanisms for blood loss, indicating early hypovolemic shock.
Pelvic fractures are highly vascular and prone to significant, hidden internal hemorrhage.
3
Determine the priority nursing action based on the PN scope of practice.
The PN must immediately escalate the critical findings to the registered nurse.
Recognizing life-threatening complications requires prompt reporting so that rapid medical interventions, such as fluid resuscitation, can be initiated.

Anahtar Kavram

Early Recognition of Hypovolemic Shock
Tahmini Süre:1m 30s
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru