MULTI SYSTEM (SHOCK AND PERFUSION) PHT 2162

MULTI SYSTEM (SHOCK AND PERFUSION) PHT 2162 The nurse is caring for a client admitted with shock secondary to severe gastrointestinal bleeding. Once the client is stabilized, what intervention should the nurse do next? 1 Monitor the peripheral pulses. 2 Check the level of consciousness. Correct3 Take a blood sample for laboratory tests. 4 Control the bleeding with a pressure dressing. A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. 11Spasticity 2Incontinence Correct3 Flaccid paralysis 4 Respiratory failure Correct5 Lack of reflexes below the injury Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Spinal shock is caused by transection of the spinal cord and results in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs as a result of decreased tone of the bladder and bowel; thus, incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating that the level of injury is below C4 and respirations are not affected. A female client who is receiving intravenous antibiotic therapy at home for treatment of toxic shock syndrome is visited by a home health nurse. What statement indicates to the nurse that the client understands the teaching regarding future care? Correct1 "I will call the clinic if I get a rash." 2 "I will call the clinic if the menstrual cramps return." 3 "I now know how to insert my diaphragm correctly." 4 "I now know how to perform correct tampon hygiene." A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client? Correct1 Encourage range of motion to the client's arm on the affected side 2 Administer the prescribed cough suppressant at the prescribed times 3 Empty and measure the drainage in the collection chamber each shift 4 Apply clamps below the insertion site when getting the client out of bed A client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse explain the function of the water? 1 Promotes pleural drainage via gravity 2 Measures the pressures in the chest wall Correct3 Prevents reflux of air back into the chest 4 Ensures bubbling in the water-seal chamber While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. What is the nurse's immediate action? 1 Place the client in the supine position 2 Spread a clamp in the insertion site to hold the site open 3 Obtain a sterile Vaseline gauze to cover the opening Correct4 Cover the opening with the cleanest material available A client who sustained serious burns now has a stress ulcer. Which clinical indicators of shock should the nurse immediately report to the primary healthcare provider? Select all that apply. Correct1 Weakness Correct2 Diaphoresis