The nurse, caring for a client diagnosed with shock, realizes that the stage in which the body attempts to remedy the problem by initiating the homeostatic mechanism would be?
1. Initial stage
2. Compensatory stage
3. Multiple organ failure stage
4. Refractory stage
2
During the compensatory stage, the body tries to remedy the problem. If it cannot, cellular damage will occur and organ failure and death may follow. During the initial stage, there is a decrease in cardiac output and impaired tissue perfusion. In multiple organ failure, every system in the body is affected. In the refractory stage, the body can no longer respond to therapy and the shock condition is considered irreversible.
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The nurse would explain to a client with a sleep disorder that alcohol intoxication
a. decreases REM sleep. b. increases sleep latency. c. increases stage 4 sleep. d. promotes periodic limb movements.
A client tells the nurse that she has noticed an increase in weight and fat deposits during the past year. The nurse reviews the client's chart and recognizes that the client is most likely going through puberty
Which nursing action is most appropriate at this time? A) Provide reassurance that these are normal changes. B) Review dietary measures to assist in controlling the weight gain. C) Encourage increased exercise to control weight gain. D) Share information on what foods can be eaten on a low-fat diet to prevent fat deposits.
How can the nurse best interpret Mrs. H's minimal eye contact in light of Mrs. H's cultural background?
A. A cultural practice reflecting unease in the healthcare environment B. A cultural practiced based on recognition of someone's social status C. A nonverbal sign of lack of respect for the other person D. A nonverbal cue that the person is not being completely truthful
A patient voids and asks to have the urinal emptied. Which of the following actions should the nurse take first?
a. Empty the urinal. b. Offer patient hand hygiene. c. Put on nonsterile gloves. d. Measure the urine.