On admission, the patient who should receive a focused assessment is the:
a. 53-year-old admitted with a perforated ulcer.
b. 5-year-old admitted for the implant of grommets in the middle ear.
c. 76-year-old admitted for a knee replacement.
d. 40-year-old admitted for possible bowel obstruction.
A
A critically ill patient should receive a focused assessment.
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Two hundred milliliters
What will be an ideal response?
A patient is admitted to the ICU for observation of his grade II splenic laceration. Which of the following signs and symptoms would suggest that he has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock?
a. BP, 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/hr; skin that is pink, warm, and dry with capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/hr; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/hr; flushed, warm, diaphoretic skin; agitated and confused
An older adult client, hospitalized post-surgery, wakes up in the middle of the night very confused. The nurse reorients the client to the surroundings and gets the client to return to sleep
Which should the nurse consider as a source for the client's confusion? A) Ambien 10 mg as needed at bedtime for sleep B) The client's age C) The death of the client's husband last month D) History of cardiac disease
A nurse anticipates that one of the benefits of a cold application will be:
A. Vasodilation B. Local anesthesia C. Reduced blood viscosity D. Increased capillary permeability