Rationales: Bleeding is the primary adverse effect of thrombolytic therapy. The nurse should establish three I.V. sites before administering therapy and should avoid giving the client I.M. injections and drawing arterial blood gases. The client should be monitored for bleeding. Reperfusion arrhythmias and hypotension may occur with thrombolytic therapy and are treated symptomatically.

Nursing process step: Evaluation

Rationales: Organic reasons for delusional behavior must be ruled out before the client is considered a psychiatric emergency. A psychiatric consult can be obtained once the client is cleared medically. Lithium isn’t the drug of choice for this client because lithium is used for bipolar disease, not schizophrenia. Insisting that the delusions aren’t real will only antagonize the client.

Nursing process step: Analysis

Rationales: A change in the client’s behavior or mental status may indicate increased intracranial pressure (ICP). The family should be advised to return with the client immediately if his behavior becomes abnormal. Aspirin should be avoided by a client with a head injury because it may increase bleeding. The use of opioids isn’t recommended because these drugs may mask signs associated with increased ICP (increased drowsiness, confusion, and lack of coordination). Symptoms of a concussion should subside within 48 hours, and the client should be reevaluated if the symptoms exceed this length of time.

Nursing process step: Intervention

Rationales: The advance directive is a legal document outlining a client’s wishes regarding health care. If the client can’t speak for himself or make decisions for himself, the durable power of attorney for health care gives another person the power to make health care decisions for him. The last will and testament and instructions for care after death aren’t read until after the client’s death.

Rationales: Precipitating factors that can cause an attack of acute gout include excessive caloric intake or overindulgence in purine-containing foods, stress, alcohol intake, and excessive vitamin A intake.

Nursing process step: Analysis

Rationales: Hypoxemia is the most common underlying cause of pediatric cardiopulmonary arrest. It leads to marked bradycardia and eventually asystole in the pediatric client. Ensuring optimum oxygenation is the most important intervention in this client population. The other options may lead to cardiopulmonary arrest in the pediatric client, but they’re much less common.

Nursing process step: Analysis

Rationales: Irrigation can cause the bean to swell and occlude the ear canal. Alligator forceps, a right-angled hook, and an ear curette can all be used to remove a vegetative foreign body.

Nursing process step: Intervention

Rationales: Most insecticides are carbamates or organophosphates and are highly lipid-soluble and easily absorbed through the skin. If protection isn’t worn, the insecticide may be absorbed through the skin of the nurse. The type and amount of insecticide spilled can be determined during the assessment. Respiratory protection is necessary if the insecticide is in a vapor or aerosol form.

Nursing process step: Analysis

Rationales: Excretory urography is the test of choice for renal pedicle repair. Dye injected into the venous system should enter the kidney and provide visualization if the renovascular system is intact. Cystography is a diagnostic tool for the bladder, and retrograde urethrography is performed for a urethral injury. A KUB X-ray shows the shape, location, and size of these organs and helps to identify masses or radiopaque calculi.

Nursing process step: Evaluation

Rationales: With an acute anterior MI, there will be ST elevation in leads V₂ through V₄, and ST depression in the inferior leads II, III, and aV_F. The ST elevations won’t be found in the other leads.

Nursing process step: Evaluation

Rationales: Common findings in a client with an open pneumothorax are sucking sounds from the wound on inspiration. A penetrating wound to the chest presents with diminished or absent breath sounds over the affected area and hyperresonance on the affected side along with dyspnea, chest pain, and tachypnea. Hemoptysis occurs most commonly with pulmonary contusion or tracheobronchial injury.

Nursing process step: Assessment

Rationales: The priority for an intubated trauma client is to assess patency of airway. Tubes can become displaced during transport from the emergency medical service unit to the trauma room. To confirm nasotracheal tube placement, the nurse should first listen for air sounds over the epigastric area. If none are present, she should then listen over both lung bases during ventilation. All other interventions may be implemented after airway, breathing, and circulation have been assessed.

Nursing process step: Intervention

Rationales: After being diagnosed with acute otitis externa, the client should be instructed to wear earplugs to keep the infected ear dry. Acute otitis externa is an inflammatory condition of the auricle and external auditory canal usually caused by gram-negative organisms. Keeping the ear dry makes it more difficult for these organisms to grow. Because of risks associated with vertigo, a client with Ménière’s disease would be instructed to change position slowly and keep his home uncluttered. A client with otitis media would be instructed to notify the physician if ear pain increases when lying down since this may indicate that antibiotic therapy is ineffective.

Nursing process step: Evaluation

Rationales: The treatment plan for a client in cardiogenic shock includes administering medications that decrease preload and afterload and increase contractility. As a result of this therapy, LVED pressure as well as demands on the heart should be reduced. Vasodilators reduce total peripheral resistance and decrease LVED pressure. Catecholamines increase heart rate, heart contractility, and vasodilatation in the postcapillary sphincters and pulmonary system. All other options are clinical manifestations of cardiogenic shock.

Nursing process step: Evaluation

Rationales: A LeFort II fracture involves a pyramidal fracture that includes the central portion of the maxilla across the superior nasal area. It may also involve the orbit. This produces a free-floating nose and dental arch. Free-floating movement of the unilateral periorbital area doesn’t describe a clinical situation. However, free-floating movement of the teeth and maxilla describes a LeFort I, and free-floating movement of all the facial bones describes a LeFort III fracture.

Nursing process step: Assessment

Rationales: It’s rare for a child to contract epididymitis, so the possibility of child molestation should be investigated. Causes of epididymitis include prostatitis, cystitis, and urethral instrumentation. Common causative organisms include Escherichia coli, Neisseria gonorrhoeae, Mycobacterium tuberculosis, and Chlamydia. Elevation of the testes sometimes relieves the pain. A client with epididymitis should be cautioned that all sexual partners should be examined and treated. Infertility can be a problem if epididymitis is untreated or partially treated because it can cause vas deferens scars or antisperm antibody production.

Nursing process step: Assessment

Rationales: An injury to the left lower ribs would be more likely to cause a splenic injury. Heart failure, sickle cell anemia, and cirrhosis are chronic disease processes that have a direct effect on the liver, making it more susceptible to injury.

Nursing process step: Evaluation

Rationales: Contracting with the client for safety is the primary focus. Although family notification, sedation, and involuntary commitment may be needed, they aren’t the priority.

Nursing process step: Assessment

Rationales: Because the client is both hypothermic and hypotensive, the priority treatment would focus on warming the client and fluid resuscitation. Although a CT scan may be indicated, the blood pressure must be addressed. Transfer to the ICU and blood transfusion may be needed following the initial treatment.

Nursing process step: Intervention

Rationales: Code #1 in the code of ethics for ED nurses states that, “The emergency nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.” Personal beliefs can’t compel the behavior of an entire profession. ED nurses may have many different personal or religious beliefs regarding human dignity, and the development of clinical expertise should coincide with a deeper understanding of ethical behavior. Clinical expertise can’t guarantee ethical behavior because ethics deals with values, actions, and choices of right and wrong. Laws are binding rules of conduct enforced by authority. In many situations, laws and ethics may overlap; however, the ethical precept of treating other human beings with dignity and law can’t mandate respect for their unique individuality.

Rationale: MAP = systolic blood pressure + (diastolic blood pressure × 2) ÷ 3. So, in this case: MAP = 126 + (70 × 2) ÷ 3; MAP = 126 + 140 ÷ 3; MAP = 88.

Nursing process step: Assessment

Rationales: The antigen-antibody reaction in anaphylactic shock induces the release of histamine, which causes massive vasodilation, a reduction in arterial pressure by dilating the arterioles, and an increase in vascular permeability. This creates a rapid shift of fluids into the interstitial spaces, and myocardial contractility is decreased because of inadequate venous return, resulting in decreased preload.

Nursing process step: Assessment

Rationales: Labile emotions, hyperactivity, hypoactivity, poor social judgment, and grandiose context to speech are classic signs of bipolar disease. Vital signs are usually normal unless other contributing factors are present. A client with bipolar disease may have impaired thinking related to rapid progression of thoughts, flight of ideas, and grandiosity. A flat or inappropriate affect is usually associated with schizophrenia.

Nursing process step: Assessment

Rationales: Nitroprusside is the first-line choice in a hypertensive crisis because it’s a mixed arterial and venous vasodilator. This makes it more effective than the other medications.

Nursing process step: Intervention

Rationales: Carbon dioxide is an acidic compound that’s normally excreted by the respiratory system. A client with COPD presents with an elevated PaCO₂, resulting in the development of respiratory acidosis and hypoxemia. Metabolic acidosis is a common finding in renal failure, dehydration, and shock. Respiratory alkalosis commonly occurs with anxiety and other states that lead to hyperventilation. Metabolic alkalosis occurs in situations with increased loss of GI fluids.

Nursing process step: Assessment

Rationales: Injuries at multiple levels on the same extremity make it unlikely that reimplantation will be successful. Loss of several digits seriously compromises hand function, so reimplantation should be considered. Reimplantation of the thumb should also be considered because the thumb constitutes 40% to 50% of the functional value of the hand due to its role in opposition and grasp and because this procedure has a high success rate. Reimplantation is usually successful in children because they regenerate transected nerves well and readily adapt to using a reimplanted part.

Nursing process step: Evaluation

Rationales: Acidosis decreases the myocardial cells, ability to respond to the countershock. Synchronized cardioversion is inappropriate in ventricular fibrillation, which should be treated with unsynchronized defibrillation. Auscultation won’t differentiate between ventricular fibrillation and asystole. The appropriate initial shock in ventricular fibrillation is 200 joules.

Nursing process step: Assessment

Rationales: Coronary vasoconstriction, abdominal cramping, water intoxication, and tissue damage from infiltration are all adverse effects of vasopressin therapy. The most serious adverse effect, however, is coronary vasoconstriction, which can cause arrhythmias, ischemia, and decreased cardiac output.

Nursing process step: Evaluation

Rationales: These symptoms suggest air embolism, which is caused by failure to exhale on ascent. Decompression sickness is caused by nitrogen bubbles in the bloodstream and is manifested by rash, fatigue, and dizziness. Nitrogen narcosis results when the client breathes dissolved nitrogen under pressure. Symptoms include fatigue, weakness, and decreased consciousness; it may result in death.

Nursing process step: Assessment

Rationales: Epigastric pain is a GI symptom associated with liver engorgement and ascites. Cardiovascular manifestations include a decrease in systolic blood pressure with an increase in diastolic blood pressure. Tachycardia, not bradycardia, may be the first clinical manifestation of heart failure as the body attempts to compensate for a failing ventricle.

Nursing process step: Assessment

Rationales: Clients don’t typically present with swelling of their hands with carpal tunnel syndrome. Weakness, paresthesia, and pain at night are all classic symptoms of carpal tunnel syndrome. Other symptoms include decreased range of motion, elbow and shoulder pain, and occasionally nail and skin involvement.

Nursing process step: Assessment

Rationales: Cocaine-induced myocardial ischemia has been associated with coronary artery vasoconstriction, coronary thrombosis, and increased myocardial oxygen consumption. In addition, these clients typically suffer from tachyarrhythmias.

Nursing process step: Evaluation

Rationales: Clients receiving beta-adrenergic blockers require large, repeated doses of epinephrine to counteract the effects of the beta-adrenergic blockers. Glucagon 5 to 15 mcg/minute I.V. may be beneficial for refractory hypotension associated with beta-adrenergic blockers. All other medications should be administered per recommended doses.

Nursing process step: Intervention

Rationales: Changes in leads II, III, and aV_F are indicative of damage to the inferior wall of the heart. The lateral wall shows changes in leads I, II, III, aV_F, V₅, and V₆. Anterior changes are shown in leads V₁ through V₄, I, and aV_L. Apical damage is shown in leads II, aV_F, V₅, and V₆.

Nursing process step: Assessment

Rationales: Clenched fists, pacing, and tense posture demonstrate escalation of violent behavior. The emergency department nurse needs to recognize this behavior early so that appropriate intervention can occur. The other options may indicate the potential for violence as well, but not to the extent that clenched fists, pacing, and tense posture do.

Nursing process step: Assessment

Rationales: Psychosis is a severe state in which a person loses the ability to interact with reality. This is evidenced by bizarre thinking, loose association of ideas, illogical speech, egocentricity, and withdrawal from relationships into an internal world of fantasies. The person may exhibit perceptual disturbances, including visual and auditory hallucinations and delusions of grandeur or persecution. Psychosis involves the loss of ego boundaries, diminished volition, and psychomotor abnormalities that demonstrate a marked decrease in reactivity to the environment. Catatonic patterns, such as stupor, posturing, unusual mannerisms, or grimacing may be present.

Nursing process step: Assessment

Rationales: The pumping ability of the heart depends on contractility (force of ventricular contraction), preload (ventricular filling and end-diastolic volume), heart rate, and afterload (pressure against which the ventricle pumps). Cardiac output and index are the result of the pumping ability of the heart.

Nursing process step: Evaluation

Rationales: A urine specific gravity of 1.050 is elevated and indicates decreased renal perfusion, possibly resulting in dehydration. The most appropriate intervention for this client is a bolus of crystalloid at 40 mL/kg. If urine output is less than 30 mL/hour, and adequate volume replacement hasn’t been achieved, the client in shock may need to have an indwelling urinary catheter inserted to monitor urine output. Furosemide 40 mg I.V. isn’t recommended in a client who’s already volumedepleted.

Nursing process step: Intervention

Rationales: Instilling a few drops of mineral oil into the ear canal will kill the insect, after which the dead insect can be removed with direct instrumentation. A cotton ball soaked in ether or 2% lidocaine will also anesthetize the insect, facilitating its removal. Normal saline and tap water are commonly used for irrigation of inorganic objects. A mixture of water and alcohol can be used for removal of organic objects because it won’t produce further swelling of the object. However, irrigation with normal saline, tap water, or alcohol diluted with water won’t readily kill the insect.

Nursing process step: Intervention

Rationales: Hydrocephalus is treated with ventricular shunts, which are surgically implanted to augment drainage of cerebrospinal fluid from the brain. Pneumocephalus is treated by evacuation of air through the use of subarachnoid screws. Encephalopathy is treated with drugs: anticonvulsants, steroids, and antibiotics. A subdural empyema is a collection of material between the dura and arachnoid layers and is treated with antimicrobial therapy and surgical drainage.

Nursing process step: Analysis

Rationales: Classic signs of cardiac tamponade include three main symptoms known as Beck’s triad. They include hypotension, muffled heart sounds, and distended neck veins. Tracheal deviation is a late sign of a tension pneumothorax.

Nursing process step: Analysis

Rationales: Herpes zoster (shingles) is characterized by clusters of vesicles that form in a line along nerve pathways. Vesicles are fluid-filled lesions less than 1 cm in size. The fluid is clear. Papules are solid masses of cellular growth usually less than 5 mm in size. Bulla are fluidfilled lesions larger than 1 cm. Pustules are fluid-filled lesions, but unlike a vesicle, the fluid inside is yellowish.

Nursing process step: Assessment

Rationales: Blood transfusions should be used judiciously to treat a crisis. They have little or no role in treatment between crises. Large doses of continuous opioid analgesics may be needed and are the mainstay of pain management during the acute phase. Oxygen is administered to treat hypoxia and control sickling. Fluids and electrolytes are given to reduce blood viscosity and maintain renal function.

Nursing process step: Intervention

Rationales: The right coronary artery supplies the right ventricle and right atrium. The inferior leads II, III, and aV_F look at the right side of the heart on the 12-lead ECG. Therefore, an ST-segment elevation observed in leads II, III, and aV_F would indicate an occlusion in the right coronary artery.

Nursing process step: Assessment

Rationales: Increased ICP is a contraindication to performing a lumbar puncture, unless the benefits outweigh the risks. Performing a lumbar puncture on a client with increased ICP may result in brain stem compression or herniation. Allergy to a local anesthetic, blood in the CSF, and the presence of a spinal cord lesion aren’t contraindications for lumbar puncture.

Nursing process step: Assessment

Rationales: A decreased platelet count may be present if a blood dyscrasia is the cause of bleeding after a bleeding episode. Decreased hemoglobin may not be immediately apparent because of hemoconcentration. Hence, more time or serial hemoglobin determinations may be necessary to detect a fall in hemoglobin readings. Prothrombin times may be elevated in bleeding clients because of bleeding disorders or anticoagulant therapy. Creatinine is a test of kidney function.

Nursing process step: Assessment

Rationales: Unless the client is ready to accept new information, building on previous knowledge is useless. The readiness factor is critical to acceptance and integration of new information. Client guilt can’t be alleviated until the client understands the intricacies of the condition and the physiologic response to the disease.

Nursing process step: Assessment

Rationales: Elevating the extremity and applying ice slow the swelling process and help relieve pain. Teaching the client how to walk with crutches isn’t appropriate at this time because the pain distracts the client. If elevating the ankle and applying ice don’t decrease the pain, then an order for medication is appropriate. A traction splint is contraindicated for this client; the traction splint is indicated for fractures of the femur and proximal tibia only.

Nursing process step: Analysis

Rationales: A client presenting with heart failure is classified as acute, which means that the client must be seen within 30 to 60 minutes of arrival at the emergency department. A client classified as urgent must be seen immediately. A nonacute client can wait in turn to be seen, and a referable client can be seen at the physician’s discretion and may be referred to another physician at another time.

Nursing process step: Evaluation

Rationales: The two causes of intrapulmonary shunt seen in the client with ARDS are pulmonary edema and atelectasis. Common treatments for hydrostatic pulmonary edema include diuretics, inotropes, and decreased fluid intake. They aren’t effective treatments for the early stages of ARDS. A key finding in ARDS is refractory hypoxemia that isn’t improved by increasing the FIO₂. In fact, FIO₂ levels greater than 60% for prolonged periods result in atelectasis, worsening ARDS, and hypoxemia. Adding low levels of PEEP (5 to 10 cm H₂O) will assist in reopening the alveoli and improving tissue oxygenation.

Nursing process step: Intervention

Rationales: Psychomotor learning requires the coordination of the brain and extremities to complete a task. Cognitive learning is a mental process that doesn’t involve the extremities. Affective learning involves feelings and attitudes rather than cognitive or psychomotor skills. Social isn’t a type of learning.

Nursing process step: Analysis

Rationales: All NSAIDs should be taken with food or on a full stomach. The client shouldn’t take NSAIDs on an empty stomach because of the possibility of gastritis or GI bleeding. Melena (dark, tarry stools) and hematochezia (bloody stools) are both symptoms of upper and lower GI bleeding. The use of NSAIDs with aspirin should be avoided. Also, it may take 1 to 2 weeks for full anti-inflammatory effects to take place.

Nursing process step: Intervention

Rationales: When preparing to irrigate a client’s right ear, the irrigation stream should be pointed toward the posterior superior aspect of the canal and not directly at the tympanic membrane. To irrigate the right ear, this would be toward the 11 o’clock position.

Nursing process step: Intervention

Rationales: Ménière’s disease is characterized by attacks of vertigo, tinnitus, a feeling of fullness in the ear, and a fluctuation of hearing ability. Labyrinthitis doesn’t usually cause a feeling of ear fullness. Otitis media doesn’t usually cause vertigo. Disequilibrium syndrome is characterized by headache and muscle cramps.

Nursing process step: Assessment

Rationales: In a pediatric client, one of the hallmark signs of radial head dislocation is the client’s refusal to use the affected arm. Other symptoms include limited supination and pain. No deformity may be obvious with this injury. Instability of the ligaments is associated with dislocations of the knee and doesn’t frequently occur. Dislocations of the patella commonly present with excessive swelling in adults. Elbow dislocations present with a loss of arm length.

Nursing process step: Assessment

Rationales: Severe hypercalcemia is a medical emergency. Continuous cardiac monitoring is necessary and emergency equipment should be readily available. Initial treatment includes vigorous hydration, possibly several hundred milliliters per hour for several hours. I.V. furosemide, not mannitol, may be given to promote diuresis. Calcitrol is a vitamin D analogue used to stimulate calcium absorption in the presence of hypocalcemia.

Nursing process step: Intervention

Rationales: A seizure immediately after a lidocaine bolus is administered may indicate lidocaine toxicity and toorapid administration of the drug. The infusion should be stopped and the client monitored while the physician is notified of this event. Neither diuretics nor digoxin is indicated in the immediate response to the seizure.

Nursing process step: Intervention

Rationales: Peptic ulcers, acute mucosal lesions (resulting from gastritis, esophagitis, or Mallory-Weiss tears), and esophageal or gastric varices are the most common causes of upper GI bleeding. Upper GI bleeding is rarely caused by neoplasms, hematologic disorders, or vascular anomalies.

Nursing process step: Assessment

Rationales: The presence of an increased number of epithelial cells, especially when they exceed the number of WBCs, is indicative of a contaminated specimen. Proper cleaning and retrieval of the specimen may not have taken place. The presence of bacteria, WBCs, and pus suggests pyelonephritis or a urinary tract infection.

Nursing process step: Evaluation

Rationales: The client with gout should avoid highpurine foods, such as anchovies, liver, sardines, most meat, and alcoholic beverages. Dairy products, whole grains, and citrus fruits have low-purine content and won’t precipitate an attack of gout.

Nursing process step: Analysis

Rationales: The earliest indicator of a change in neurologic status is the LOC. A client who exhibits altered mental status or decreased LOC should be reevaluated by a nurse and a physician. A change in the reaction or shape of pupils is a late indicator of a neurologic problem. Motor response appears as a delayed sign of neurologic status changes. Capillary refill is an indicator of circulatory status.

Nursing process step: Assessment

Rationales: Intussusception occurs most often in infants and toddlers aged 3 months to 2 years. They may present with a triad of crampy abdominal pain, vomiting, and bloody (currant jelly) stools. A sausage-shaped mass may be palpable in the right upper quadrant. Right lower quadrant tenderness at McBurney’s point is associated with appendicitis. Cullen’s sign, periumbilical ecchymosis, is consistent with a traumatic injury causing peritoneal bleeding. An olive-shaped mass in the upper abdomen is associated with pyloric stenosis, a narrowing of the outflow tract of the stomach.

Nursing process step: Assessment

Rationales: The use of accessory muscles indicates worsening respiratory function. The client also has increased pain when moving. Increased pain leads to increased blood pressure and a tendency to breath shallowly. For these reasons, it’s important to provide adequate pain medication to decrease the complications of immobility.

Nursing process step: Evaluation

Rationales: Fentanyl is an opioid, and the antidote for opioids is naloxone. Physostigmine is the antidote for anticholinergics except cyclic antidepressants. Flumazenil is the antidote for benzodiazepines, and atropine is the antidote for organophosphates.

Nursing process step: Intervention

Rationales: A fat embolism occurs after a bone fracture or surgical manipulation of bone. A fat embolus is a small fat globule that has been displaced into the blood. The origin, although largely unknown, is believed to be either from the fracture site or from altered lipid solubility brought on by the stress of the traumatic event. The fat globules can occlude blood vessels in the brain, lungs, heart, and other organs. Symptoms include a recent fracture or bone surgery, dyspnea, sudden onset of substernal chest pain, hemoptysis, cough, crackles, altered mental status, fever, and petechiae to the buccal membranes, conjunctiva, chest, neck, shoulders, or axillary folds. Because these symptoms closely mimic other syndromes, such as pulmonary embolus and MI, careful attention must be given to the circumstances surrounding the onset of symptoms and to the client’s medical history.

Nursing process step: Analysis

Rationales: A child with epiglottitis has a sudden high fever, marked drooling, stridor, and severe sore throat. A child with retropharyngeal abscess has abrupt onset of high fever, stridor, drooling, severe sore throat, hyperextension of the head, and stiff neck. In bacterial tracheitis, the fever is mild initially, followed by an acute increase; the child will also have a barking cough. Bacterial tracheitis doesn’t cause drooling, and sore throat, if present at all, will be minimal. Viral croup syndrome causes a variable temperature (100° to 104° F [37.8° to 40° C]), barking cough, and mild (if any) sore throat; it doesn’t cause drooling.

Nursing process step: Analysis

Rationales: Alligator forceps are used to remove vegetable or other foreign bodies from the ear. The nurse also needs a good light source, large ear speculums, an ear curette, and ear suction. If the foreign body isn’t a vegetable, a 30-mL syringe filled with water may be used to irrigate the ear—however, water shouldn’t be used to remove vegetables because it causes them to swell, making removal more difficult. Lidocaine is useful in removing live bugs. Cerumenex is useful in removing earwax buildup only.

Nursing process step: Intervention

Rationales: Muscular contraction or tension headache is an example of a nonvascular headache. Skeletal muscle contraction in the head or neck produces steady, pulsatile pain and limited motion of the head, neck, and jaw. Rigorous ROM causes increased pain. Pressure over contracted muscles worsens the pain, as do vasoconstrictor drugs such as ergotamine. A warm towel will induce vasodilatation and muscle relaxation.

Nursing process step: Intervention

Rationales: DIC is a condition of excessive coagulation that eventually leads to inadequate homeostasis. The activation of the coagulation system leads to the formation of fibrin that binds with blood to form a clot. In DIC, the clots are deposited in the microvasculature of various organs. Excessive bleeding in DIC results from the consumption of all clotting factors. Fibrin degradation products further aggravate this situation because they act as powerful anticoagulants. Heparin is most effective when administered soon after recognition of symptoms. Fresh frozen plasma and cryoprecipitate are administered to replace clotting factors. Although the client is at risk for thrombus and emboli, thrombolytic agents, such as urokinase, streptokinase, and tPa, aren’t used because they can cause excessive bleeding.

Nursing process step: Intervention

Rationales: Lens displacement usually occurs as a result of direct trauma to the globe. Fibers around the iris break and the lens subluxes, causing diplopia, distortion, decreased visual acuity, and no response to light. A globe rupture would cause severe pain and a complete loss of vision. Hyphema results in pain in the affected eye and blurred vision. A retinal detachment usually produces flashing and visible floaters in the eye.

Nursing process step: Assessment

Rationales: Inflammatory processes, such as diverticulitis, cause an increase in neutrophils, or neutrophilia. Many viral diseases, such as hepatitis, influenza, and measles, as reflected in the other options, can cause a decreased neutrophil count, or neutropenia.

Nursing process step: Analysis

Rationales: Signs of a mandibular fracture include malocclusion, ecchymosis of the floor of the mouth, and sublingual edema. A zygotic, LeFort, or maxillary fracture wouldn’t cause ecchymosis of the floor of the mouth.

Nursing process step: Assessment

Rationales: Arteriography is helpful if diminished or absent pulses indicate that there may be vascular damage. It isn’t clinically indicated for long bone injuries if the vascular status is unaffected. Arteriography isn’t usually indicated in open injuries (including penetrating injury) unless the wound is near major vascular structures or the wounding force was high-velocity.

Nursing process step: Assessment

Rationales: The risk for infection is high in this client; therefore, administration of antibiotics is a priority. If other severe injuries are present and they compromise respiratory function, immediate intubation or chest tube insertion may be necessary. Insertion of an NG tube is contraindicated.

Nursing process step: Intervention

Rationales: This client is having a hemolytic reaction to transfusion therapy. Therefore, the transfusion should be stopped immediately. The nurse should then initiate infusion of normal saline solution at a keep-vein-open rate. After contacting a physician, the nurse should be prepared to administer antihistamines and epinephrine. The client’s vital signs should be reassessed frequently, as indicated by facility policy.

Nursing process step: Intervention

Rationales: Corticosteroids reduce inflammation and cerebral edema and help prevent increased intracranial pressure. Anticonvulsants are used to control absence seizures. Antipsychotics and antianxiety drugs may be used sparingly to control agitation. Preferably, nonopioids are used to relieve pain. Opioids may make it difficult to assess the client’s level of consciousness.

Nursing process step: Intervention

Rationales: Adrenal crisis may occur as the result of sudden withdrawal from corticosteroid therapy. Symptoms of adrenal crisis include fever, myalgia, arthralgia, and malaise. An increased risk of developing glaucoma and subcapsular cataracts can be the result of prolonged use of corticosteroids. Psychiatric disturbances may present as an adverse effect during use, and they may include euphoria, insomnia, mood swings, and extreme depression. Tardive dyskinesia consists of irreversible, involuntary movements that may develop in people being treated with neuroleptics such as chlorpromazine.

Nursing process step: Analysis

Rationales: Complications of rewarming include metabolic acidosis, cardiac arrhythmias, pneumonia, renal failure, pancreatitis, sepsis, and acute respiratory distress syndrome. The application of warm blankets isn’t sufficient with such severe hypothermia. More active rewarming (peritoneal dialysis, warmed fluids, heated humidified oxygen, extracorporeal blood rewarming) may be needed. Rapid rewarming isn’t advised because such a client is vulnerable to cardiac arrhythmias. External rewarming causes peripheral vasodilation. This action may divert blood flow to the skin and shunt cooled blood to the central circulation, thereby causing a brief drop in core temperature. It may also predispose the client to hypovolemia and ventricular fibrillation. Debilitated and elderly clients with core temperatures under 95° F (35° C) should be hospitalized.

Nursing process step: Intervention

Rationales: The lowest level of electrical energy required to initiate consistent capture with a pacemaker is referred to as pacing threshold. It’s determined by achieving pacing at a high level and then gradually decreasing the energy level until capture ceases. For successful capture, the energy is then set a few milliamperes above the threshold. Underdrive pacing is used to interrupt tachyarrhythmias. Demand pacers fire only when the heart rate drops below a set rate.

Nursing process step: Evaluation

Rationales: Hyperosmolality is the result of accompanying hyperglycemia and hypernatremia. Hyperosmolality causes insulin levels to be reduced, preventing the movement of glucose into the cells and allowing glucose to accumulate in the plasma. HHNS is characterized by extremely elevated blood glucose levels, which range from 600 mg/dL to 2,800 mg/dL. The BUN level is normally elevated from severe dehydration. Fluid volume deficit is more severe than in diabetic ketoacidosis—up to 12 L of fluid must be replaced. Mild metabolic acidosis is reflected in ABG results from poor perfusion and anaerobic metabolism.

Nursing process step: Assessment

Rationales: A sprain is the tearing of ligaments that results in inflammation and ecchymotic discoloration. An abrasion is a partial-thickness scraping away of the skin. A contusion is a closed wound in which ruptured blood vessels have hemorrhaged into the surrounding tissue and are self-contained.

Nursing process step: Assessment

Rationales: The key diagnostic finding suggesting a ruptured diaphragm is the presence of bowel sounds in the middle of the chest. The left side of the diaphragm is more likely to be injured than the right side because it isn’t as well protected. The abdominal contents herniate into the chest, causing compression of the lungs and great vessels. Hemothorax would produce diminished breath sounds but not shoulder pain or bowel sounds in the chest. Aortic dissection may cause a shift of heart sounds; however, the client decompensates quickly. A tracheobronchial disruption produces signs consistent with pneumothorax.

Nursing process step: Assessment

Rationales: Increased fluid intake facilitates increased kidney excretion of calcium. Immobility, especially for extended periods, rather than exercise, causes calcium to leave the bones and become concentrated in the extracellular fluid. From there, it passes through the kidneys and precipitates to form calculi. Milk is high in calcium and should be restricted in a client with hypercalcemia.

Nursing process step: Evaluation