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Zorluk: OrtaPhysiological Adaptation

A client with liver cirrhosis and a recent history of esophageal varices is resting in a medical-surgical unit. Upon assuming care, the practical nurse notes a baseline blood pressure of 106/72 mm Hg and a heart rate of 94 beats per minute. An hour later, the client suddenly becomes restless, begins pulling at the bed linens, and has pale, diaphoretic skin. Which action should the practical nurse take first?

  1. A
    Administer a prescribed as-needed dose of medication for the acute agitation.
  2. Reassess the client's blood pressure and pulse rate immediately.Cevap
  3. C
    Document the behavioral changes and plan to recheck vital signs at the next scheduled time.
  4. D
    Dim the room lights and encourage the client to practice deep breathing.

Cevap

The priority action is to reassess the client's blood pressure and pulse rate immediately to evaluate for signs of hypovolemic shock.
The correct action is to immediately measure the client's vital signs. A client with a history of esophageal varices is at high risk for internal hemorrhage. Sudden restlessness, pallor, and diaphoresis, combined with an earlier borderline heart rate, are classic early signs of hypovolemic shock. The practical nurse must gather objective hemodynamic data (blood pressure and pulse) to report to the registered nurse for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and medical history.
The client has a high risk for bleeding due to esophageal varices and is exhibiting sudden restlessness, pallor, and diaphoresis after having borderline tachycardia.
Identifying the underlying risk for hemorrhage is crucial for accurate clinical judgment and prioritization.
2
Evaluate the new symptoms using the Airway, Breathing, Circulation (ABC) framework.
The client's acute changes in mental status and skin condition strongly suggest compromised circulation and decreased cerebral perfusion.
Recognizing early physiological signs of hypovolemic shock ensures that life-threatening complications are addressed before secondary issues.
3
Select the most appropriate initial action within the practical nurse's scope of practice.
Measuring current vital signs is the immediate priority to obtain objective hemodynamic data.
Current vital signs are necessary to confirm clinical suspicions before escalating the situation to the registered nurse or healthcare provider.

Anahtar Kavram

Early Recognition of Hypovolemic Shock
Tahmini Süre:1m 0s
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Konular

Physiological Adaptation

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