Examkin

Soru

Zorluk: OrtaPhysiological Adaptation

A nurse receives the shift report for a group of assigned clients on a medical-surgical trauma unit. Which client requires the nurse's immediate assessment and intervention?

  1. A client with blunt abdominal trauma whose heart rate has steadily increased from 82 to 114 beats per minute over the past hour.Cevap
  2. B
    A client with severe chronic obstructive pulmonary disease (COPD) whose arterial blood gas reveals a pH of 7.36, a PaCO2 of 54 mmHg, and an HCO3 of 30 mEq/L.
  3. C
    An older adult client with moderate Alzheimer's disease who is pacing the unit hallway and repeatedly asking when their family will arrive.
  4. D
    A client who underwent a right femoral cardiac catheterization three hours ago and is resting quietly in a completely flat, supine position.

Cevap

The client with blunt abdominal trauma and a steadily increasing heart rate requires immediate assessment.
The correct answer describes a client exhibiting a classic early sign of hypovolemic shock (tachycardia) following blunt abdominal trauma. The sympathetic nervous system increases the heart rate to maintain cardiac output as blood volume decreases from internal hemorrhage. This is a life-threatening physiological crisis requiring immediate intervention to stabilize the client's circulation.

Adım Adım Çözüm

1
Evaluate the clinical data for the client with blunt abdominal trauma.
The heart rate has increased significantly from 82 to 114 beats per minute, which is a cardinal early sign of compensatory shock.
Trauma clients are at high risk for covert internal bleeding, such as a splenic or hepatic laceration.
2
Analyze the arterial blood gas (ABG) for the client with COPD.
A pH of 7.36 (normal), PaCO2 of 54 (high), and HCO3 of 30 (high) indicates a fully compensated respiratory acidosis.
Recognizing chronic baseline compensation prevents the nurse from mistaking a stable chronic condition for an acute respiratory emergency.
3
Assess the positioning of the post-cardiac catheterization client.
The client is flat and supine, which is the medically prescribed position to prevent femoral artery bleeding.
Correct positioning confirms the client's current status is safe and expected.
4
Compare all clients to determine the highest priority based on the ABCs (Airway, Breathing, Circulation).
The trauma client with progressive tachycardia has an acute circulation threat, making them the absolute highest priority.
Prioritization requires identifying acute, life-threatening changes over expected or stable chronic findings.

Anahtar Kavram

Prioritizing Acute Physiological Decompensation over Expected Chronic Findings
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru