Examkin

Soru

Zorluk: OrtaPhysiological Adaptation

While providing care for an elderly client admitted with community-acquired pneumonia, the nurse notes a sudden shift in the client's baseline mental status, characterized by agitation and confusion. An immediate assessment yields the following data: blood pressure 86/52 mm Hg, heart rate 118 beats/min, respiratory rate 26 breaths/min, and an oral temperature of 96.8°F (36.0°C). Which intervention must the nurse execute first?

  1. Notify the rapid response team and prepare to administer an isotonic fluid bolus.Cevap
  2. B
    Request a prescription for a mild sedative to manage the client's acute restlessness.
  3. C
    Document the new-onset confusion as an expected, age-related response to hospitalization.
  4. D
    Apply warmed blankets to correct the subnormal temperature before reassessing the blood pressure.

Cevap

The nurse must prioritize notifying the rapid response team and initiating an isotonic fluid bolus to treat impending septic shock.
The correct answer emphasizes immediate circulatory support. The client's clinical picture—hypotension, tachycardia, tachypnea, hypothermia, and a sudden change in mental status—indicates progression to septic shock. Because perfusion is severely compromised, the highest priority according to the ABC (Airway, Breathing, Circulation) framework is to notify the rapid response team and restore intravascular volume with isotonic crystalloid fluids.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client exhibits new-onset confusion, hypothermia (96.8°F / 36.0°C), tachycardia (118 beats/min), tachypnea (26 breaths/min), and severe hypotension (86/52 mm Hg).
Identifying abnormal assessment findings and recognizing acute deviations from the baseline is the foundational step in clinical reasoning.
2
Synthesize the findings to identify the underlying pathophysiological process.
The combination of these signs in an older adult with an existing infection strongly indicates systemic inflammatory response syndrome (SIRS) progressing to septic shock.
Older adults frequently present atypically with severe infections, often manifesting hypothermia and altered mental status rather than a traditional high fever.
3
Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).
Circulatory collapse, evidenced by the severe hypotension and compensatory tachycardia, requires immediate life-saving intervention with fluid resuscitation.
Restoring intravascular volume is critical to reverse poor tissue perfusion and prevent irreversible multiorgan failure.

Anahtar Kavram

Early Recognition and Management of Septic Shock in Older Adults
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Konular

Physiological Adaptation

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