HESI Week 9

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1. bradycardia 2. hypotension 3. spastic paralysis 4. bladder dysfunction 5. increased pulse pressure

1. bradycardia 2. hypotension 4. bladder dysfunction Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in hypotension. Bladder dysfunction in the form of urinary retention or oliguria may occur in spinal shock. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

The nurse is assessing a client with an open fracture who is in a trauma condition. What are the nursing interventions in order of priority? 1.Assessing for airway patency, breathing, and circulation 2.Administering morphine sulfate intravenously 3.Applying direct pressure on the injured area 4.Cutting away the clothing from the fracture site

1.Assessing for airway patency, breathing, and circulation 4.Cutting away the clothing from the fracture site 3.Applying direct pressure on the injured area 2.Administering morphine sulfate intravenously The priority nursing intervention for a client in a trauma condition is to assess for airway patency, breathing, and circulation. Next priority is to cut away clothing from the fractured site. After clothing is removed, direct pressure is applied on the injured area to prevent bleeding. After stabilizing the client, pain is managed by administering morphine sulfate through the intravenous route.

which acid-base imbalance would the nurse anticipate in a client in the progressive stage of shock? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

a. metabolic acidosis result of accumulated lactic acid

which clinical manifestation would the nurse observe in a client experiencing anaphylactic shock from a type I latex allergic reaction? select all that apply a. stridor b. fissuring c. hypotension d. dyspnea e. cracking of the skin

a. stridor c. hypotension d. dyspnea

how would the nurse describe cardiogenic shock when a family member of a client asks for more information about the condition? a. an irreversible phenomenon b. a failure of the circulatory pump c. usually a fleeting reaction to tissue injury d. generally caused by decreased volume

b. a failure of the circulatory pump ineffective cardiac pumping or contraction is the cause of poor peripheral circulation

which change in the client's lab results indicates the client is experiencing septic shock? a. blood glucose of 80 b. an increased serum lactate level c. an increased neutrophil level d. a white blood count (WBC) of 5000 cells

b. an increased serum lactate level

which color tag is assigned for the lowest priority for care in a mass casualty event? a. red b. black c. green d. yellow

b. black 0-black: lethal injuries and will usually die despite treatment

the nurse would utilize the glasgow coma scale on a trauma client to complete which assessment? a. patency of airway b. level of consciousness c. breathing abnormalities d. circulatory abnormalities

b. level of consciousness less than 8, intubate

which type of shock is associated with a ruptured abdominal aneurysm? a. vasogenic shock b. neurogenic shock c. cardiogenic shock d. hypovolemic shock

d. hypovolemic shock fluid volume depletion occurs because the heart continues to pump blood out of the ruptured vessel

When a norepinephrine intravenous infusion is prescribed for a client in septic shock, which intravenous line would the nurse choose for the infusion? a. implanted port b. midline catheter c. 18 gauge peripheral venous catheter d. peripherally inserted central catheter line (PICC)

d. peripherally inserted central catheter line (PICC) norepinephrine is a vesicant needs to be pushed through a central line