A client is diagnosed with failure of the left ventricle to provide adequate delivery of oxygen to the body tissues due to a weakened forward pumping function of the heart. The nurse realizes this client is experiencing:
1. anaphylactic reaction.
2. cardiogenic shock.
3. hypovolemia.
4. metabolic acidosis.
2
In cardiogenic shock, there is an impaired forward pumping function with decreased stroke volume and decreased cardiac output. This dysfunction results in a backup of blood into the pulmonary system, and it can cause metabolic acidosis. Anaphylactic shock is a systemic reaction to an antigen. Hypovolemia is a loss of circulating blood. Metabolic acidosis is an acid-base imbalance that can occur from a variety of health conditions or disease processes.
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In which circumstance would a psychiatric forensic nurse examiner determine that it would be appropriate for the defendant and his attorney to consider the legal insanity defense?
a. The defendant experienced auditory hallucinations that he perceived as the voice of God commanding him to drown his child. b. The accused tampered with the brakes of his wife's car after discovering she had had an affair. c. The charged inmate shot the drug dealer who refused to give her cocaine when she had no money to buy it. d. The defendant, frightened because his house had been robbed the night before, assumed his son was a burglar and shot him.
While the older African American is at the highest risk for developing Alzheimer's disease, the nurse demonstrates an understanding of this disease process's risk factors when assessing this population's:
a. weight and elimination patterns. b. heart rate and capillary refill status. c. blood pressure and serum lipid levels. d. muscle strength and reflex times.
The nurse understands that communication includes a cognitive process. This part of the process:
a. is when the receiver interprets and gives meaning to stimuli. b. is the medium through which a message is transmitted. c. refers to spoken words and cues. d. relates to the distance between persons.
A patient with heart failure is facing the end of life. Which intervention would the nurse prioritize with this patient?
1. Have the health care provider discuss end-of-life topics with the patient. 2. Tell the patient that the family should be the primary source of support, but that nursing staff will be glad to substitute if necessary. 3. Be as honest as possible about the progression of the disease and the support needed. 4. Reassure the patient that death will be painless.