A client who has experienced a myocardial infarction develops left ventricular heart failure. Which sign of poor organ perfusion should the nurse remain alert for?
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.
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A) True B) False
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Indicate whether the statement is true or false
The nurse observes that when an 8-year-old boy enters the playroom, he often causes disruption by taking toys from other children. The nurse's best approach for this behavior is to
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