The nurse provides comfort measures to maintain normal body temperature and reduce pain and anxiety for a patient who is experiencing shock. Which of the following benefits do these measures provide?
a. Decreased fluid volume
b. Increased fluid volume
c. Decreased oxygen demand
d. Increased oxygen demand
ANS: C
Pain, anxiety, and cold all increase tissue demands for blood and oxygen, which places increased workload on the heart to supply it.
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A pregnant adolescent asks the nurse, "Why does the physician call measuring my uterus a ‘fundal height'?" The nurse's answer is based on the fact that the fundus of the uterus is located:
1. In the elongated portion where the fallopian tubes enter. 2. In the lower third area. 3. At the uppermost (dome-shaped top) portion. 4. Between the internal cervical os and the endometrial cavity.
When the nurse inspects the feet of a diabetic, a tack is found sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding?
A) In diabetes, the autonomic nerves are affected. B) Motor neuropathy causes muscles to weaken and atrophy. C) High blood sugar decreases blood circulation to nerves. D) Nephropathy is a common complication of diabetes mellitus.
A client has been diagnosed with a dissociative disorder. What treatments would the nurse know could be used for this client? (Mark all that apply.)
A) Electroconvulsive therapy B) Seclusion therapy C) Hypnosis D) Creative art processes E) Cognitive techniques
A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take?
A) Document the finding, as it is a normal finding at this time. B) Contact the physician, as it indicates early DIC. C) Contact the physician, as it is a first sign of postpartum eclampsia. D) Obtain an order for a CBC, as it suggests postpartum anemia.