Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction?
1. Strong bounding pulse with deep red coloring
2. Pale, cool extremities with decreased pulses
3. Increased venous engorgement with strong pulses
4. Faster than normal capillary refill time
2
Rationale 1: An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and is not present with increased peripheral resistance and vasoconstriction.
Rationale 2: Increased peripheral resistance causes the blood supply to decrease and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply.
Rationale 3: Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance.
Rationale 4: Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance.
You might also like to view...
A patient being assessed by the physician states, "I wet my pants every time I cough." The nurse recognizes this as which type of incontinence?
a. Reflex b. Overflow c. Urge d. Stress
You would expect a patient who has normal hearing to report which of the following after a Rinne test?
a. hearing the sound longer through air conduction b. hearing the sound longer through bone conduction c. hearing the sound louder through bone conduction d. hearing the sound through air and bone conduction for an equal period of time
The nurse is evaluating a patient admitted to the emergency department with an evolving STEMI for possible administration of thrombolytic therapy. Which of the following identified during history taking would contraindicate this type of therapy?
a. The patient just completed her last menstrual cycle. b. The patient states that the chest pain started 1 hour ago. c. The patient has a history of a small cerebral aneurysm. d. The patient has hypertension that is well controlled by diuretic therapy.
The nurse is caring for a client with leukemia who is experiencing a blast crisis. What is the nurse's understanding of the client's condition? Select all that apply.
A) A blast crisis is the rapid proliferation of immature cells. B) The new cells resulting from the client's condition have distinct morphology and specialized functions. C) This condition occurs in early stage leukemias, such as chronic myelogenous leukemia. D) The most immature cells in the body are labeled as blast cells. E) The cells resulting from a blast crisis are found in the bone marrow and/or blood.