The critical care nurse is assessing a client for clinical signs of shock. Which assessment finding does the nurse understand to be a clinical sign of shock?
A) Polydipsia
B) Headache
C) Nausea
D) Cold, clammy skin
D) Cold, clammy skin
Explanation: A) Polydipsia, headache, and nausea are not considered clinical signs of shock.
B) Polydipsia, headache, and nausea are not considered clinical signs of shock.
C) Polydipsia, headache, and nausea are not considered clinical signs of shock.
D) Clinical signs of tissue hypoperfusion are evident in cold, clammy skin as a result of vasoconstriction and cyanosis in a client experiencing shock.
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Which of the following is an appropriate nursing diagnosis for this patient?
A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL a. Impaired Gas Exchange related to ineffective breathing b. Excess Fluid Volume related to limited fluid output c. Deficient Fluid Volume related to abnormal fluid loss d. Electrolyte Imbalance related to decreased oral intake
Anemia is a common health alteration affecting men at a much higher rate than women
Indicate whether the statement is true or false.
The amino acid that plays an important role in the gastrointestinal tract during stress is
a. arginine. b. glutamine. c. methionine. d. phenylalanine.
What action(s) by the staff nurse is an effective way to deal with a sexual harassment issue in the workplace? (Select all that apply.)
a. Tell the person to stop. b. Tell your best friend about the incident. c. File a formal grievance. d. Explain the situation to your spouse. e. Play along with the person and document the activities. f. Threaten the person with a sexual harass-ment lawsuit.