The nurse is assessing a client for systemic inflammatory response syndrome (SIRS). Which of the following disease processes are associated with this syndrome? (Select all that apply.)
1. Infection
2. Pancreatitis
3. Ischemia
4. Trauma
5. Massive transfusions
6. Heart failure
1, 2, 3, 4, 5
Disease processes associated with systemic inflammatory response syndrome include infection, pancreatitis, ischemia, trauma, and massive transfusions. Heart failure is associated with cardiogenic shock.
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The nursing action that takes priority when working with a patient who has a problem of sexual dysfunction or disorder is:
a. acquiring knowledge of the patient's sexual roles. b. developing an understanding of human sexual response. c. clarifying the nurse's personal values about sexuality. d. assessing the patient's sexual functioning and needs.
Internal version might be used to manipulate the:
a. Fetus from a breech to a cephalic presentation before labor begins. b. Fetus from a transverse lie to a longitudinal lie before cesarean birth. c. Second twin from an oblique lie to a transverse lie before labor begins. d. Second twin from a transverse lie to a breech presentation during vaginal birth.
A patient is admitted to the emergency department with a blood alcohol level of 0.45%. The nurse should immediately prepare to administer which intervention?
a. CPR b. Intravenous fluids c. Respiratory support d. Naloxone (Narcan)
A child presents to the Emergency Department with cardiac pump failure, and subsequently develops hypovolemic shock. Which assessment finding would the nurse recognize as an indicator of early hypovolemic shock?
1. Decreased blood pressure 2. Weak central pulses 3. Pale, cold skin 4. Tachycardia