When a client has posttraumatic stress disorder (PTSD), it is most important for the nurse to realize that memory traces are deeply imprinted and may be:
A) Recalled as a lack of ability to startle.
B) Recalled when the amygdala suppresses stress hormones.
C) Reactivated when there are decreased levels of adrenaline.
D) Reactivated as if the traumatic event was reoccurring.
D
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A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements?
a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.
The nurse must order a meal tray for a Jewish client who is off the unit for testing and will require insulin administration immediately upon returning to the unit. Which dietary selection is the most appropriate for this client?
1. BLT sandwich, potato salad, fruit wedge, and unsweetened tea. 2. Roast beef sandwich, potato chips, and 2% milk. 3. Egg salad sandwich, side salad, applesauce, and diet soda. 4. Pork tenderloin sandwich, fruit cup, and milk.
A nurse is explaining to a family member the pathophysiologic characteristic of vasogenic shock. What information should the nurse include?
a. The intravascular compartment fills beyond capacity, allowing fluid to leak out, compressing vital organs. b. The circulating volume causes excessive constriction of the vessels, causing blood pooling. c. Widely fluctuating blood pressures stimu-late vascular collapse, causing severe al-terations in peripheral perfusion. d. Although the circulating volume is intact, excessive vascular dilation causes drastic drops in the blood pressure.
A patient with an acute kidney injury is identified as being at risk for infection. Which nursing interventions are indicated?
1. Turn and reposition when necessary. 2. Avoid manipulation of venous access devices. 3. Post signs to remind visitors and staff to wash their hands. 4. Limit the use of antibiotic therapy. 5. Remove invasive devices as soon as medically possible.