NR341 Week 8
EDAPT
Your response is correct!
The four changes in the client’s condition that indicate their condition has deteriorated include:
•The bruising in the left groin due to blood lost at the site of the cardiac
catheterization site indicates deterioration.
•The decrease in blood pressure to 80/50 and MAP to 60 both signify less
circulating blood volume.
•The increased pulse is in response to the decreased perfusion at the cellular level.
•The decreased pulse oximetry (SpO2) indicates hypoxemia caused by decreased
perfusion through the lungs.
The low blood pressure alarm alerts the nurse to assess the client but does not indicate that a
change in their condition has occurred as it may be related to an equipment malfunction and the
client is fine. The nurse applying direct pressure to the L groin is an intervention implemented
because of the bruising. There has been no change in the client’s respirations, most likely
because of the light anesthesia administered during the procedure.
Your response is correct!
Cellular hypoperfusion secondary to hypotension due to myocardial infarction can contribute to:
•ventilation-perfusion mismatch due to inadequate blood flow to the lungs
•anasarca, or wide-spread edema, secondary to altered capillary permeability
allowing protein and fluid leaks from the blood to the interstitial spaces
•ischemia of fingers and toes due to lack of oxygen
•increased ammonia levels due to hepatic hypoperfusion
Cellular hypoperfusion of the neurologic system will result in hyporeflexia (not hyperreflexia).
Cellular hypoperfusion of the hepatic system will contribute to increased lactate levels, not
decreased.
Your response is correct!
The client is at highest risk for developing cardiogenic shock caused by the acute myocardial
infarction (AMI) and renal failure due to decreased perfusion of the kidneys.
The overall decrease in cardiac output with shock will cause decreased (not increased)
intracranial pressure and hypotension (not hypertension). While the decreased cardiac output can
contribute to both deep vein thrombosis and pressure ulcers, these are not the highest risk for the
client at this time.
