A patient presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?
A) Compensation
B) Irreversible
C) Early
D) Decompensation
D
Feedback:
The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis. Therefore, options A, B, and C are incorrect.
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A. "No, at your age, fluctuations in your menstrual cycle are normal findings." B. "No, menopause only begins in women after the age of 55." C. "Yes, not having a period for more than 6 months is diagnostic of menopause." D. "You have to go 1 year without a menstrual period to be sure that menopause has occurred."
The nurse identifies the diagnosis of Risk for Injury as appropriate for a client with preeclampsia. Which should the nurse include in this client's plan of care?
A) Suggest family and friends phone frequently. B) Place in a semiprivate room. C) Provide stimulation with television and visitors. D) Limit phone calls and visitors.
A patient, unsure of the need for surgery, asks the nurse, "What should I do?" What answer by the nurse is based on advocacy?
A) "If I were you, I sure would not have this surgical procedure." B) "Gosh, I don't know what I would do if I were you." C) "Tell me more about what makes you think you don't want surgery." D) "Let me talk to your doctor and I will get back to you as soon as I can."
A client newly diagnosed with a terminal illness asks to talk with the hospital chaplain and requests a Bible to read. What do these client behaviors indicate to the nurse?
1. The client does not have any family members to discuss spiritual issues. 2. The client is searching for answers. 3. The client wants to talk with someone other than the nurse about spiritual concerns. 4. Interventions for Spiritual Distress have been effective.