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Zorluk: KolayPhysiological Adaptation

A practical nurse (PN) is caring for an older adult client who is receiving treatment for a urinary tract infection (UTI). Which assessment findings indicate a potential systemic complication that requires immediate reporting to the registered nurse (RN)? Select all that apply.

  1. Blood pressure decreasing from 134/82 mm Hg to 90/58 mm HgCevap
  2. Heart rate increasing from 78 to 116 beats/minuteCevap
  3. New onset of acute confusion and agitationCevap
  4. D
    Client reports of a burning sensation during urination
  5. E
    Collection of cloudy, dark yellow urine

Cevap

The findings that require immediate reporting are a blood pressure drop to 90/58 mm Hg, a heart rate increase to 116 beats/minute, and a new onset of acute confusion.
A significant drop in blood pressure, an increasing heart rate, and new onset of confusion are clinical indicators of physiological decompensation, specifically systemic infection (sepsis) and poor tissue perfusion. These acute changes represent a direct threat to circulation and require immediate escalation to the registered nurse for emergency intervention.

Adım Adım Çözüm

1
Analyze the client's current diagnosis and baseline status.
The client has a UTI, which can progress to a severe systemic infection (sepsis) if it worsens or is left untreated.
Understanding the primary diagnosis helps the nurse anticipate potential complications.
2
Evaluate each assessment finding to distinguish between expected localized symptoms and unexpected systemic complications.
Burning during urination and cloudy urine are expected localized symptoms. The changes in vital signs and mental status are unexpected systemic changes.
Nurses must be able to differentiate normal disease manifestations from acute physiological deterioration.
3
Apply prioritization principles, specifically looking for airway, breathing, or circulation (ABC) threats.
The systemic changes (hypotension, tachycardia, altered mental status) threaten circulation and tissue perfusion, requiring immediate reporting.
Life-threatening circulatory issues always take precedence over localized, expected symptoms.

Anahtar Kavram

Prioritization of systemic signs of infection and hypoperfusion over expected localized symptoms
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Konular

Physiological Adaptation

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