B. Denial
The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's grief model by ignoring that the client's death is imminent (A, C, and
... [Show More] D) are stages of grief that are not being displayed by the client's spouse during this observation.
The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes pattern. After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit?
A. Acceptance
B. Denial
C. Bargaining
D. Depression
A.
Cold applications produce a topical anesthetic effect to reduce pain as well as constrict blood vessels to minimize bruising (A). Local ice over an injured area will not lower the core temperature (B). The cold pack causes vasoconstriction which reduces circulation, not (C), to traumatized tissue and limits further edema around the injury (D), but not by reabsorption of edematous fluid.
The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate?
A. Reduced pain and minimized bruising.
B. Lowering of body core temperature.
C. Increased circulation around injury.
D. Reabsorption of edema at injury.
A. Diminished hair on legs
C. Skin cool to touch.
Diminished hair on the legs (A) and skin that is cool to the touch (C) are symptoms of decreased arterial blood flow. (B, D, and E) are not indicators for impaired circulation.
The registered nurse (RN) palpates a weak pedal pulse on the client'rs right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation (Select all that apply.)
A. Diminished hair on legs.
B. Bruising on extremities.
C. Skin cool to touch.
D. Capillary refill less than 3 seconds.
E. Darkened skin on extremities.
C. Lethargy
Changes in the level of consciousness occur in the early stages of shock which decreases the perfusion to the brain which is manifested as lethargy (C). The respiratory rate increases, not (D). (A and B) are late signs of hypovolemic shock due to cardiac compensatory measures.
Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock?
A. Faint pedal pulses
B. Decrease in blood pressure.
C. Lethargy.
D. Slow breathing.
D. Rise slowly when getting out of bed or chair.
The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which has the side effect of orthostatic hypotension. Instructing the client to rise from a chair or bed slowly (D) is indicated to avoid dizziness and falling. (A, B, and C) are not indicated when taking an ACE inhibitor.
The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalapril to manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication?
A. Take the medication at bedtime.
B. Report presence of increased bruising.
C. Check pulse before taking medication.
D. Rise slowly when getting out of bed or chair.
A. Prepare the client for a chest x-ray at the bedside.
A chest x-ray (A) should be performed immediately after the procedure to ensure lung expansion has been maintained after removal of the chest tube. (B) provides additional data after removal of the CT. (C) may assist the client to breathe easily, but the priority after chest tube removal is to ensure that the procedure was successful. The entire system, including the chest tube is discarded and not taken apart (D).
The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after removal of the chest tube?
A. Prepare the client for chest x-ray at the bedside.
B. Review arterial blood gases after removal.
C. Elevate the head of the bed to 45 degrees.
D. Assist with disassembling the drainage system. [Show Less]