The nurse is assessing a patient for septic shock. Which statement best describes this health problem?
1. Sepsis with hypotension that does not correct itself when a fluid challenge is administered
2. Sepsis with hypotension accompanied by decreased protein C levels and coagulation abnormalities
3. Sepsis with hypotension accompanied by increased creatinine and absent bowel sounds
4. Sepsis with hypotension accompanied by altered mental status and lactic acidosis
1
Rationale 1: Septic shock is defined by the presence of sepsis plus refractory hypotension.
Rationale 2: In septic shock, protein C would be elevated as a result of fibrinolysis.
Rationale 3: This describes severe sepsis with signs of organ failure but not specifically septic shock.
Rationale 4: This describes severe sepsis with signs of organ failure but not specifically septic shock.
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The telephone rings at the nurses' station of an inpatient psychiatric facility. The caller asks to speak with Ms. Honey. Which nursing response protects the patient's rights and confidentiality?
A. "I cannot confirm or deny that Ms. Honey was admitted here." B. "Ms. Honey is in group therapy at present." C. "Hold on, I'll go see if she is in her room." D. "Are you a family member? Ms. Honey can only receive calls from family members."
The nurse inserts an NGT and the client begins to cough and gag. Which should the nurse implement for the client's benefit?
1. Withdraw the tube slightly and ask the client to swallow. 2. Stop the procedure, anchor the tube, and request an x-ray. 3. Tell the client the gagging will pass and advance the tube. 4. Remove the tube and allow the client to regain composure.
A nurse is teaching adolescent boys about pubertal changes. Which is the first sign of pubertal change seen with boys?
a. Testicular enlargement b. Facial hair c. Scrotal enlargement d. Voice deepens
The nurse is educating a patient about his diagnosis of stage II Hodgkin disease. Which statement indicates that the nurse's teaching has been successful?
a. "The cancer has spread throughout my entire body." b. "There is only one lymph node involved." c. "The lymph nodes in both of my arms are affected." d. "Two nodes in my left arm area are af-fected."