A client is dying of Alzheimer disease and is being cared for in an inpatient setting for his last days. In anticipation of the client's imminent death, assessments and interventions have been limited to those necessary to maintain comfort
However, the nurse has taken a set of vital signs in response to signs of multiple organ failure. What vital signs are consistent with multiple organ failure? Select all that apply. A) Hypotension
B) Hypothermia
C) Bradypnea
D) A weak, thready pulse
E) Increased oxygen saturation
A, D
Feedback:
Multiple organ failure is often accompanied by hypotension and a weak, irregular pulse. Hypothermia and low respiratory rate are less common than fever and dyspnea or increased irregular respirations. It would be unusual for oxygen saturation to increase near death.
You might also like to view...
A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How should the nurse respond?
a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."
What are the factors about which the nurse should advise a client after a breast biopsy procedure?
A) Caring for the wound, using a mild analgesic, wearing a supportive brassiere, and timing of a follow-up appointment B) Consuming foods rich in fat and starch and not consuming more than a 1,000 mL water during a day C) Wearing tight-fitting garments and drug abuse D) Doing a breast self-examination at least once a day and consuming foods rich in protein and fiber
The nurse is reviewing the results of a patient's urinalysis. Which of the following is considered normal within a urine specimen?
a. protein c. ketones b. glucose d. sodium
The nurse on the pediatric unit is assigned to care for four children. One of the children is 18 months old and the rest are 3, 4, and 4-1/2 years old
The youngest is in for observation, the 3-year-old has a cardiac problem, and the two older children are in for tests. After a report the nurse takes the children's vital signs. The nurse would need to take the pulses in which of the following ways? a. radial pulse on all the children b. radial on the two older children and apical on the 18-month-old and the child with a cardiac problem c. apical on all children under 5 d. apical only on the child with a cardiac problem