While A.H. awaits his surgery, it is important that you monitor him carefully for decreased tissue perfusion
Identify five things you would assess for, and state your rationale for each.
Urinary output: A decrease in kidney perfusion will result in decreased urine production.
Abdominal or lumbosacral pain: An increase in pain can mean enlargement of the aneurysm or
possible leakage.
Bowel sounds: Decreased or absent bowel sounds can indicate decreased perfusion of the
gastrointestinal (GI) tract.
Peripheral circulation: Decrease in pedal pulses, coolness, cyanosis, or mottling of the skin of the feet,
or increase in capillary refill time, indicates impaired peripheral circulation.
Chest pain: If perfusion of the myocardium is decreased, the heart can become ischemic.
VS: Hypotension, tachycardia, and tachypnea are signs of hypovolemia or hemorrhagic shock.
Level of consciousness (LOC): If cerebral perfusion is diminished, the patient might become confused
and anxious.
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A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
a. Ineffective airway clearance b. Ineffective coping c. Ineffective denial d. Risk for injury
Mental health clinicians working from an ecological theoretical perspective would suggest violent behavior is:
a. a neurologically based instinctual drive b. a part of the socialization process c. a basic instinct of displaced self-destructive impulses d. influenced by interactions among personal predisposition, relationships, community, and society
Which of the following nursing interventions fall within the standards of psychiatric–mental health clinical nursing practice for a nurse generalist? Select all that apply
A. Assist clients to perform activities of daily living. B. Act as a consultant with other clinicians to provide services for clients and effect system change C. Encourage clients to discuss triggers for relapse D. Use prescriptive authority in accordance with state and federal laws E. Educate families about signs and symptoms of alcohol dependence and withdrawal
When utilizing the health care system in the United Kingdom, it is expected that the community health nurse will experience
a. An equal employer-citizen share in cost of health care b. Ownership and operation of the system by the government c. Nurse practitioners as the primary providers of care in the system d. Primary care provided in hospitals