A patient, recovering from multiple traumas caused from a motor vehicle accident, has been in the intensive care unit for 4 days
Which of the following clinical findings would suggest to the nurse that the patient is experiencing a metabolic stress response? 1. respiratory rate 18 per minute
2. insulin ineffective to reduce rising blood glucose level
3. heart rate 88 and regular
4. urine output 50 cc/hour
2
Rationale: The flow phase of the metabolic stress response peaks in 3 to 4 days after the initial physiological injury. Evidence of the flow phase includes tachycardia, tachypnea, and increased cardiac output. Hyperglycemia is seen after injury because glucose production is needed to meet the body's demands. Catecholamines released at the time of injury add to the rising glucose level. Because of this, the administration of insulin in efforts to reduce the blood glucose level may be ineffective at this time. The respiratory rate of 18 per minute is a normal rate and not tachypnea. The heart rate of 88 beats per minute is a normal rate and not tachycardia. A urine output of 50 cc/hour is a normal urine output.
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