A client is in the clinic and tells the nurse that the family was hiking and came across a snake. The client told the family to run, but became concerned when the client's heart rate felt very high. The best response by the nurse is:
1. "I will ask the doctor to order an ECG."
2. "That is your adrenal glands protecting you."
3. "You should probably make an appointment with a cardiologist."
4. "You were just frightened."
Answer: 2
1. Since the client's bodily responses were normal, it is not necessary to ask for an ECG.
2. The adrenal medulla produces epinephrine and norepinephrine, which activates the flight or fight response by raising the blood pressure and heart rate to allow for immediate action. The response is a protective mechanism by the adrenal gland.
3. It would not be appropriate for the nurse to suggest a cardiology consult for a normal bodily response.
4. The client was frightened, but the nurse should explain to the client why the body responded as it did to alleviate the client's concern.
You might also like to view...
The nurse assesses that the patient is having a sympathetic response when noting what manifestations?
A) Decrease in sweating, decrease in respirations, and pupil constriction B) Decrease in heart rate and perfusion, and an increase in inflammatory reactions C) Increase in blood pressure, bronchodilation, and decreased bowel sounds D) Increased motility and secretions in the GI tract, and constriction of bronchi and pupils
A client is informed that a surgical procedure is to be scheduled in 2 weeks. Which teaching points should the nurse focus to prepare the client for the surgery?
Select all that apply. A) Maintaining a patent airway B) Deep breathing and coughing C) Caring for the surgical incision D) Managing constipation E) Managing pain
The nurse administers a vaginal suppository. What information should the nurse include in patient teaching about postadministration care?
a. Use a tampon to hold the suppository in place. b. Place a perineal pad in her underpants when getting up. c. Expect a moderate localized burning and itching. d. Remain in the semi-Fowler's position for 2 hours.
Cooling blankets should be used:
1. in a crisis only. 2. on top of the client. 3. beneath the client. 4. wrapped around the client.