Which of the following patient responses would best indicate that resuscitation efforts have improved the shock state resulting from traumatic injuries?
1. blood pressure of 120/80 mm Hg
2. base deficit
3. heart rate of 88 beats per minute
4. CVP of 4 mm Hg
2
Rationale: Traditional signs of sufficient tissue perfusion, such as normal blood pressure, heart rate, CVP, and urine output, cannot be used to evaluate the resolution of shock states because normal vital signs and urine output may be the result of compensatory mechanisms (renin–angiotensin–aldosterone and sympathetic nervous system). Current guidelines recommend the use of base deficit, lactate, and gastric pH as endpoints to evaluate the effectiveness of shock management.
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a. Administer prescribed sedatives or opioids at bedtime to promote sleep. b. Cluster nursing activities so that the patient has uninterrupted rest periods. c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. d. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.
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A) "Keeping fit and dealing with stress in a positive way helps your chances of living to be 100." B) "Surviving to 100 is strongly impacted by eating meat, fruits and grains." C) "Those people in your socioeconomic situation have higher chance of living to 100." D) "You have had a cancer and a stroke, so that decreases your chance of surviving to 100."
The nurse is confident that the young adult has successfully achieved psychosocial development when the client:
1. Discusses his plans to expand his exercise routine to include running. 2. Is optimistic about finding a new job since losing his last month. 3. Shares that he volunteers weekly at the local senior center. 4. Recognizes that while he enjoys playing basketball recreationally, he will never play professionally. 5. Laughs that next year he'll be "too bald" to play Santa Claus.
A 12-year-old boy presents with marked respiratory distress; hot, moist skin; and anxiety. He is sitting with his chin thrust forward and has inspiratory stridor. According to the child's grandmother, his symptoms began suddenly about 30 minutes ago. You should be MOST suspicious for:
A) acute viral croup. B) bacterial epiglottitis. C) subglottic narrowing. D) laryngotracheobronchitis.