Following the morning handoff report, a practical nurse (PN) begins data collection for a group of assigned clients. Which client findings represent acute physiological deterioration and require immediate intervention? Select all that apply.
- A client with a deep vein thrombosis who suddenly develops a cough and rapid breathing.Cevap
- A client who is 2 hours post-appendectomy and exhibits a steady heart rate increase from 80 to 115 beats per minute.Cevap
- A client receiving intravenous insulin whose skin becomes pale, cold, and clammy while becoming highly agitated.Cevap
- DA client with a closed tibia fracture who is crying and urgently requesting pain medication.
- EAn older adult client with advanced dementia who is completely unable to state their current location.
- FA client who is 24 hours postpartum and has saturated one perineal pad over the past 4 hours.
Cevap
The correct findings indicating acute physiological deterioration are the client with a deep vein thrombosis developing a cough and rapid breathing, the post-appendectomy client with a rising heart rate, and the client on insulin exhibiting pale, clammy skin with agitation.
The correct findings all represent acute, life-threatening physiological changes. Sudden respiratory distress in a DVT client suggests a pulmonary embolism. A rising heart rate post-surgery is a classic early sign of internal bleeding and shock. Agitation with cold, clammy skin during insulin therapy indicates profound hypoglycemia. All three require immediate nursing intervention.
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Prioritization of Acute Physiological Deterioration