After K.B. has been on the unit for 6 hours, you identify the following changes in her assessment data:
K.B. is difficult to arouse.
but when awake she is able to identify who and where she is; PeRRLA 1+ with
slower reaction time than earlier; color pale, pink; skin cool and clammy; heart rate 126 beats/min, respi-
ratory rate 28 breaths/min, temperature (oral) 99 ° F (37.2 ° C); spo2
90%. The findings of the neurovascular
checks of the affected extremities are unchanged.
What will your immediate nursing interventions include?
• Monitor airway. Administer O2
and note whether saturation rises immediately.
• Monitor cardiovascular status, IV patency.
• Reassess neurologic status and include the Glasgow Coma Scale (eye opening, verbal response,
motor response) and respiratory status (rate, rhythm, effort, skin color, breath sounds).
• Compare current assessment data with previous data.
• Notify physician immediately.
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A patient with a preexisting pulmonary illness is being seen in the clinic for a routine assessment. The patient says, "My family and I are going skiing for our next vacation.". What information should the nurse provide?
1. "Going to high altitudes is not a good idea for your health.". 2. "You should be watchful for any respiratory problems while you are there.". 3. "You should go to the seashore instead.". 4. "Be certain to fly directly to the resort if possible.".
The nurse is assessing a client's precordium. Which of the following should be included in this assessment? (Select all that apply.)
1. Palpate the precordium. 2. Palpate temperature and pulses of extremities. 3. Assess blood pressure. 4. Percuss the precordium. 5. Auscultate heart sounds. 6. Identify the location and timing of heart sounds.
What is the goal of pharmacologic therapy in treating Parkinson's disease?
1. Increase the amount of acetylcholine at the presynaptic neurons. 2. Decrease the amount of dopamine available in the substantia nigra. 3. Balance cholinergic and dopaminergic activity in the brain. 4. Block dopamine receptors in both presynaptic and postsynaptic neurons.
Parameters that define the term "team" in the text include
a. Interdependent members b. Intradependent members c. Need to coordinate efforts d. Desire to collaborate