A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate?
Select all that apply.
A) Tachycardia
B) Increased blood glucose level
C) Decreased breath sounds
D) Confusion
E) Thick, tenacious bronchial secretions
Answer: A, C, D
Clinical manifestations of DIC include decreased breath sounds, tachycardia, and confusion. Increased blood glucose and thick bronchial secretions are not associated with this health problem.
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A patient who has cystitis has been told to drink at least 30 mL for each kilogram of body weight. Her weight is 154 lb. How many mL/day should the nurse instruct the patient to drink?
a. 1500 b. 2100 c. 2700 d. 3100
When monitoring for the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is
a. central venous pressure (CVP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP).
Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process?
1. "I work with my ancillary staff to be able to determine what is abnormal." 2. "The skin is easy to observe for abnormalities when you are giving the bath." 3. "I use the time to really look at my clients and determine what's normal and what's not." 4. "Bath time is an excellent time to get to know your clients and form that nurse-client relationship."
Skeletal muscle relaxation is desirable in diseases such as ________.
A. cerebral palsy B. Alzheimer's disease C. glaucoma D. urinary retention