The Nurse Obtains All of the Following Assessment Data About

question 26

Multiple Choice

The nurse obtains all of the following assessment data about a patient with fluid-volume deficit caused by a massive burn injury. Which of the following assessment data will be of greatest concern?

• A) Oral fluid intake is 100 ml for the last 8 hours.
• B) The blood pressure is 90/40 mm Hg.
• C) Urine output is 30 ml over the last hour.
• D) There is prolonged skin tenting over the sternum.

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Definitions:

Generous

Being willing to give more of something, such as money or time, than is strictly necessary or expected.

Actual Self-views

An individual's perception of their own real attributes, capabilities, and characteristics, as opposed to their ideal self or how others perceive them.

Michelangelo Phenomenon

The concept that close relationships can help individuals sculpt each other towards their ideal selves.

Significant-construct Experience

Involves experiences that fundamentally shape or contribute to the building of personal or theoretical frameworks.