A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,500 mL of blood
Based on this data, which type of hemorrhagic shock is the client experiencing?
A) Class I
B) Class II
C) Class III
D) Class IV
Answer: C
This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-2,000mL or 30% to 40% of blood volume.
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Your patient has multiple open wounds that require treatment. When performing dressing changes, you should:
a. Remove all of the soiled dressings before beginning wound treatment b. Cleanse wounds from most contaminated to least contaminated c. Treat wounds on the patient's side first, then the front and back of the patient d. Irrigate wounds from least contaminated to most contaminated
Jorgio has recently learned in his studying of heart failure that his uncle had cardiogenic pulmonary edema. He wants to know if this is related to heart failure and, if so, how. He comes to you to help explain this to him
a. Discuss how cardiogenic pulmonary edema and left-sided heart failure are related. b. What are some of the complications? c. What are the expected findings or symptoms when assessing a client with this disorder? d. What treatment is recommended?
An example of rationalizing is
a. restricting food intake by rationing food. b. coping with stress using biofeedback techniques. c. identifying emotional triggers for eating. d. using a busy schedule to justify poor food choices.
A patient with psoriasis tells the nurse that she has quit her job as a receptionist because she feels her appearance is disgusting to customers. The nursing diagnosis that best describes this patient response is:
A. ineffective coping related to social support B. impaired skin integrity related to lesions C. anxiety related to lack of knowledge of the disease process D. social isolation relate to decreased activities secondary to fear of rejection