The nurse is assessing a client following a myocardial infarction. The client is hypotensive. What additional assessment finding does the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the si-noatrial (SA) node. This results in an increase in heart rate. This tachycardia is an early response and is seen even when blood pressure is not critically low.
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The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care?
a. The suction is discontinued when the patient is ambulated to the bathroom. b. The collection device is emptied at the end of the shift and output recorded in the chart. c. The patient's bed is placed in the semi-Fowler's position to facilitate lung reexpansion. d. The patient is encouraged to use his incentive spirometer at least 10 times every hour.
A nurse who shares knowledge about and involves patients in health care decisions is demonstrating:
a. power over. c. power with. b. power protection. d. power control.
The childhood trait that increases the risk for developing an antisocial personality disorder is
1. poor impulse control. 2. frequently reading in solitude. 3. poor preschool learning practices. 4. difficulty controlling others in the environment.
Which nursing assessment would alert a nurse to the development of a mediastinal shift, in a client with tension pneumothorax?
A) Fluctuation of the fluid in the water-seal chamber B) Shift of rib cage toward affected side C) Sucking sound heard on inspiration and expiration D) Shift of trachea, esophagus, heart, and great vessels