The nurse is assessing a client who has left ventricular failure secondary to a myocardial infarction. Which clinical manifestation of poor organ perfusion does the nurse monitor for in this client?
a. Headache
b. Hypertension
c. Urine output of less than 30 mL/hr
d. Heart rate of 55 to 60 beats/min
C
The nurse should remain alert for signs of poor organ perfusion that are the result of decreased cardiac output. When the kidneys are not well perfused, urine output drops to less than 30 mL/hr. Other signs include changes in mental status; cool, clammy extremities with decreased or absent pulses; fatigue; and recurrent chest pain. The other manifestations do not indicate poor organ perfusion.
You might also like to view...
During an evaluation conference, the nurse manager observes nonverbal messages, including nodding in agreement and smiling. These behaviors are examples of which aspect of communication?
1. Metacommunication 2. Intrasender conflict 3. Fogging 4. Intersender conflict
Purposely hurting a family pet is a warning sign of other types of abuse in the home
Indicate whether the statement is true or false.
In developing an end-of-life plan of care for the client, the nurse should identify which hygiene goal as appropriate?
1. Provide hourly sponge baths for end-of-life comfort. 2. Involve the client in 30% of her bath daily. 3. Maintain clean skin by providing daily whirlpool baths. 4. Involve the family in hygiene care daily to maintain clean, dry skin.
The nurse explains to a 51-year-old professional tennis instructor who is diagnosed with osteoarthritis that the disease is best understood as the:
1. presence of antibodies in the synovial fluid. 2. dislocation of the patella over the tibia. 3. degeneration of articular cartilage. 4. body's autoimmune response.