A patient is hospitalized for acute respiratory distress related to pneumonia and has improved. On admission she had been very anxious because she could not get her breath
On the night shift, she is found to be restless and disorganized in her behavior and conversation. Which of the following nursing interventions should be implemented first? a. Check her pulse oximetry reading.
b. Administer supplemental oxygen.
c. Reassure her that she is improving.
d. Guide her to use relaxation exercises.
A
Hypoxia can cause mental and behavioral changes that can be mistaken for anxiety, including restlessness, disorganization, and confusion. Therefore, further assessment is needed before assuming that the signs noted here are due to anxiety. A simple check for hypoxia is pulse oximetry, and this should be checked immediately any time hypoxia is a possibility. It would be premature to attempt any of the other interventions here until hypoxia was ruled in or out as the likely cause of this patient's presentation.
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