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Zorluk: ZorPhysiological Adaptation

A 76-year-old client, who is on strict bed rest recovering from an ischemic stroke, has been calm and oriented. The client abruptly becomes highly agitated, attempts to pull off their gown, and reports a feeling of impending doom. Current vital signs show a heart rate of 112 beats/minute, a respiratory rate of 24 breaths/minute, and a blood pressure of 118/74 mm Hg. Which action should the practical nurse take first?

  1. Elevate the head of the bed to a high Fowler's position and measure the oxygen saturation levelCevap
  2. B
    Reorient the client to the current environment and decrease sensory stimulation in the room
  3. C
    Ask the client about their pain level and prepare to offer a prescribed oral analgesic
  4. D
    Document the episode of agitation, as the vital signs reflect normal physiological changes for this age

Cevap

Elevate the head of the bed to a high Fowler's position and measure the oxygen saturation level
The correct answer addresses the client's Airway, Breathing, and Circulation (ABC) priorities. Sudden agitation, restlessness, a feeling of impending doom, tachypnea, and tachycardia in a bedbound client are classic early signs of hypoxia, potentially from a pulmonary embolism. The nurse must prioritize respiratory support by immediately elevating the head of the bed to maximize lung expansion and collecting oxygenation data before notifying the registered nurse.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has sudden onset agitation, a feeling of impending doom, tachypnea (respiratory rate of 24), and tachycardia (heart rate of 112) while on prolonged bed rest.
Identifying the cluster of symptoms helps differentiate between psychological/behavioral issues and physiological deterioration.
2
Determine the most life-threatening potential complication.
The combination of immobility and sudden respiratory distress strongly suggests a pulmonary embolism or acute hypoxia.
Sudden confusion or agitation in older adults should always be treated as hypoxia or an acute physiological event until proven otherwise.
3
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
Interventions that support Breathing (positioning) and assess oxygenation (pulse oximetry) take immediate precedence over comfort or behavioral measures.
Maximizing lung expansion and identifying the severity of hypoxia are the most critical immediate actions within the practical nurse scope of practice.

Anahtar Kavram

Prioritizing ABCs and recognizing subtle signs of hypoxia in older adults
Tahmini Süre:1m 15s
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Konular

Physiological Adaptation

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