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Zorluk: OrtaPhysiological Adaptation

An 80-year-old client with a history of mild cognitive impairment and chronic bronchitis is admitted for a suspected urinary tract infection. Upon entering the room, the practical nurse observes the client is highly restless, picking at the bedsheets, and speaking incoherently. Current vital signs are: temperature 99.1°F (37.3°C), heart rate 112 beats/min, respiratory rate 26 breaths/min, blood pressure 102/60 mm Hg, and oxygen saturation 89% on room air. Which action should the practical nurse take first?

  1. Elevate the head of the bed, apply supplemental oxygen, and notify the registered nurse.Cevap
  2. B
    Implement strict fall precautions and attempt to verbally de-escalate the client's agitation.
  3. C
    Administer a prescribed as-needed mild analgesic, assuming the elevated heart rate is due to discomfort.
  4. D
    Record the new behavioral changes as an expected progression of the client's underlying cognitive impairment.

Cevap

Elevate the head of the bed, apply supplemental oxygen, and notify the registered nurse.
The client is demonstrating signs of acute hypoxia (oxygen saturation of 89%, tachypnea, and new-onset restlessness). According to the ABC (Airway, Breathing, Circulation) priority framework, the nurse must first address the compromised breathing and oxygenation by positioning the client to optimize lung expansion, applying oxygen, and immediately escalating the critical findings to the registered nurse.

Adım Adım Çözüm

1
Analyze the client's vital signs and clinical presentation.
Identified oxygen saturation of 89%, tachypnea, tachycardia, and sudden acute agitation.
To establish the client's current physiological status and identify any immediate life-threatening abnormalities.
2
Apply a clinical prioritization framework.
Determined that Breathing (oxygenation) is severely compromised and is the likely cause of the acute restlessness.
The ABC (Airway, Breathing, Circulation) framework dictates that respiratory deficits must be addressed before secondary safety or psychosocial concerns.
3
Determine the most appropriate immediate nursing intervention.
Selected interventions to improve oxygenation (head elevation, oxygen application) and escalate care.
Immediate correction of hypoxia is required to prevent further physiological deterioration, and critical vital signs must be reported to the RN.

Anahtar Kavram

Airway, Breathing, and Circulation (ABC) prioritization in acute physiological deterioration
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Konular

Physiological Adaptation

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