The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.)
a. Blood pressure
b. Heart rate
c. Level of consciousness
d. Pupil response
e. Respirations
f. Urine output
A, C, F
The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response does not assess perfusion. Respirations do not assess perfusion.
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People have problems accessing health care primarily because of:
a. lack of community support. b. lack of resources. c. poor intellectual ability. d. state government rules and regulations.
A problem with assessment data may be that
a. the data are comprehensive b. the client may be unwilling to share data c. complete validation is needed d. the nursing diagnosis is clear
What underlying pathophysiology explains the gradual graying of an older adult's hair?
a. Reduced hair follicles b. Less sebaceous gland activity c. Loss of collagen fibers in dermis d. Decreased melanocytes at hair follicle
A patient with a temporary loss of motor function is diagnosed with a transient ischemic attack (TIA). What should the nurse include when assisting in the teaching about this health problem?
a. "You had a small hemorrhage in your brain." b. "Your brain was temporarily deprived of oxygen." c. "The neurons in your brain are tangled, so messages get mixed up." d. "You have a vessel that is occluded, blocking the blood supply to your brain."