Upon entering the client's room and performing an initial assessment, the nurse finds the client to have warm, flushed skin, fever above 100.4 degrees F, mild tachycardia, and a respiratory rate of 26
The nurse suspects the client is in which phase of septic shock? a. early c. advanced
b. moderate d. late
A
Early symptoms of septic shock include warm, flushed skin, fever above 100.4 degrees Fahrenheit, mild tachycardia and elevated respiratory rate above 20 breaths/minute, and a white blood cell count lower than 4,000 or greater than 10,000 . At this point the client's blood pressure and pulse oximetry are usually normal. As sepsis progresses the client may become anxious, start to show mild hypotension, hypoxia, higher fever and more significant mental status changes as well as worsening of tachycardia and metabolic acidosis occurs. As the sepsis progresses into septic shock, the client exhibits severe tachycardia, cool and clammy extremities, weak and thready peripheral pulses and significant hypotension as well as hypoxia and respiratory distress. The client may be unresponsive and have minimal urine output.
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A 25-year-old female with brain metastases asks the nurse about the length of time she has to live
Based upon the fact that the patient is not receiving treatment for the brain metastases, the nurse's best response is that patients with this condition generally have a mean survival time of what? A) 2 weeks B) 1 month C) 6 months D) 1 year
When instilling nose drops, a small pillow may be placed under the child's shoulders to aid in the flow of the medicine through the ________ passage.
Fill in the blank(s) with the appropriate word(s).
Mr. Lee comes to the office for a routine health assessment. As part of it, you perform a screening MS exam. This consists of all the following except:
A. inspection and palpation of joints integrated with each body region. B. observation of ROM as the individual proceeds through motions required for preparation for the exam and during the exam. C. testing muscle strength of the major muscle groups. D. age-specific measures.
Prior to initiating medication therapy with phenelzine (Nardil), the nurse should plan to determine the patient's:
a. Mood and affect b. Activity level c. Cognitive ability to understand information about the medication d. Support network and its members' willingness to participate in treatment