Nursing III Exam III Chapter 65
The nurse is caring for a client who has sustained multiple injuries from a motor vehicle accident. The nurse realizes
... [Show More] that the client will have a release of stress hormones that are useful for all of the following EXCEPT:
Preventing ingestion of food
The nurse is planning care for a client diagnosed with acute respiratory distress syndrome (ARDS)? Which of the following is not included in the management of this disorder?
Promoting urine output
The nurse, caring for a client diagnosed with shock, realizes that the stage in which the body attempts to remedy the problem by initiating the homeostatic mechanism would be?
Compensatory stage
A client experiences a bee sting, complains of difficulty breathing, and shows sign of hypoxia and hypotension. The nurse realizes these are signs of anaphylactic shock, and she should do which of the following first?
Give epinephrine intravenously or via endotracheal tube
A client is diagnosed with failure of the left ventricle to provide adequate delivery of oxygen to the body tissues due to a weakened forward pumping function of the heart. The nurse realizes this client is experiencing:
cardiogenic shock
To assess if the renal system in a client diagnosed with multisystem failure is functioning properly, the nurse would expect to see urine output of:
30 mL per hour
The nurse realizes that a client, diagnosed with neurogenic shock, is at risk for developing: deep vein thrombosis
A client is diagnosed with septic shock. The nurse realizes that the major cause of this type of shock is:
gram-negative bacteria
A client is diagnosed with cardiogenic shock. The nurse should plan interventions to address which of the following potential complications of this disorder?
Myocardial infarction
The nurse is concerned that a client will develop neurogenic shock when which of the following is assessed?
Spinal cord injury at T1
The nurse is planning care for a client diagnosed with disseminated intravascular coagulation. Which of the following should be included in this plan of care?
Avoid intramuscular injections
A firefighter is brought to the emergency department with complaints of headache, weakness, shortness of breath, cough, and chest pain. During the assessment of this client, the nurse realizes the client should be evaluated for:
Cyanide poisoning
The nurse is assessing a client for the acute phase of the inflammatory immune response. Which of the following are considered cardinal signs of this response? (Select all that apply.) Rubor
Tumor Dolor Calor
The nurse is determining if a client is experiencing chronic inflammation. Which of the following are indications for this type of inflammation? (Select all that apply.)
Chronic elevation of white blood cells Low-grade fever
Pain
Scar formation
The nurse is assessing a client for systemic inflammatory response syndrome (SIRS). Which of the following disease processes are associated with this syndrome? (Select all that apply.) Infection
Pancreatitis Ischemia Trauma
Massive transfusions
A client is experiencing symptoms associated with distributive shock. What types of shock are included in this category? (Select all that apply.)
Neurogenic Anaphylactic Septic
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