0315: Client presents for altered mental status and was brought to the ED by his wife. The wife reports that she was awakened by him not being beside her and found him in the living room knocking objects over and was unable to communicate effectively. The wife reports that the CPAP he uses overnight was damaged, and has been unable to use for the past two nights. On assessment, the client is anxious and confused. He responds to verbal commands but has no insight into why he is in the ED. Lung sounds are diminished in the bases, with wheezes in the upper lobes. Peripheral pulses are 2+. The client has a history of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, diabetes mellitus, and dyslipidemia.
Pulse 99
Respiratory rate 23
Blood pressure 139/89 mm Hg
Temperature 99.5° F (37.5° C)
Pulse oximetry 91% on room air
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress
Action to Take: Administer oxygen via non-rebreather mask | Obtain a prescription for a bronchodilator | Obtain a prescription for glucagon | Obtain a prescription for a benzodiazepine | Obtain a prescription for bilevel positive airway pressure (BiPap)
Potential Conditions: Metabolic acidosis | Hypoglycemia | Respiratory alkalosis | Respiratory acidosis
Parameter to Monitor: Neurological status | Arterial blood gas | Capillary blood glucose | Urinary output
Action to Take: Administer oxygen via non-rebreather mask | Obtain a prescription for a bronchodilator | Obtain a prescription for glucagon | Obtain a prescription for a benzodiazepine | Obtain a prescription for bilevel positive airway pressure (BiPap)
Parameter to Monitor: Neurological status | Arterial blood gas | Capillary blood glucose | Urinary output
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