A burn client experiences excessive fluid in the interstitial spaces causing edema. Because the fluid accumulation impairs peripheral circulation, the nurse assesses the client for which of the following complications?
A)
increase in cardiac output
B)
tissue necrosis
C)
increased diuresis
D)
impaired mobility
B
Explanation:
A)
The impaired circulation caused by the edema leads to a decrease in blood flow to tissues, which can in turn cause tissue death. Fluid trapped in the interstitial spaces is pulled from the vascular volume, resulting in a decrease in cardiac output and diuresis.
Analysis
Assessment
Physiological Integrity: Reduction of Risk Potential
B)
The impaired circulation caused by the edema leads to a decrease in blood flow to tissues, which can in turn cause tissue death. Fluid trapped in the interstitial spaces is pulled from the vascular volume, resulting in a decrease in cardiac output and diuresis.
Analysis
Assessment
Physiological Integrity: Reduction of Risk Potential
C)
The impaired circulation caused by the edema leads to a decrease in blood flow to tissues, which can in turn cause tissue death. Fluid trapped in the interstitial spaces is pulled from the vascular volume, resulting in a decrease in cardiac output and diuresis.
Analysis
Assessment
Physiological Integrity: Reduction of Risk Potential
D)
The impaired circulation caused by the edema leads to a decrease in blood flow to tissues, which can in turn cause tissue death. Fluid trapped in the interstitial spaces is pulled from the vascular volume, resulting in a decrease in cardiac output and diuresis.
Analysis
Assessment
Physiological Integrity: Reduction of Risk Potential
You might also like to view...
The nurse-manager explains to a new nurse at the ambulatory clinic that the service for which the telephone nursing practice is not feasible is
a. assessing a client's needs based on the nurse's perception. b. developing a collaborative plan of care with a client. c. evaluating outcomes of practice and care. d. prioritizing the urgency of a client's needs.
Concerning the woman's reordering of personal relationships during pregnancy, a maternity nurse should be aware that:
1. because of the special motherhood bond, a woman's relationship with her mother is even more important than with the father of the child. 2. nurses need not get involved in any sexual issues the couple has during pregnan-cy, particularly if they have trouble communicating them to each other. 3. women usually express two major relationship needs during pregnancy: feeling loved and valued and having the child accepted by the father. 4. the woman's sexual desire is likely to be highest in the first trimester because of the excitement and because intercourse is physically easier.
The nurse is screening children before they enter preschool. The expected visual acuity at this age is:
A) 20/20, B) 20/40, C) 20/60, D) 20/100,
A nurse is caring for a man who states he is ready to start exercising. Which of the following actions should the nurse take next?
a. Do nothing because he has already made the decision to implement a change. b. Provide him with information on the benefits of exercising. c. Develop an exercise prescription with him. d. Schedule a follow-up in 2 months to see if he still feels the same way.