A nurse is caring for a client who experienced severe head trauma. The client's partner asks the nurse why they are concerned about the mean arterial pressure (MAP). The nurse should explain that MAP determines which of the following?
Cerebral blood flow
The client's intake and output needs
Regulation of blood pressure
Resorption of cerebrospinal fluid
The Correct Answer is A
A. Cerebral blood flow. MAP is crucial for maintaining adequate cerebral perfusion pressure, ensuring enough blood flow to the brain.
B. The client's intake and output needs. MAP does not directly influence intake and output needs; it is more directly related to blood flow and tissue perfusion.
C. Regulation of blood pressure. MAP is a measure of average blood pressure but not a regulator of it.
D. Resorption of cerebrospinal fluid. CSF resorption is not directly influenced by MAP; it’s regulated by intracranial pressure and other factors.
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Correct Answer is B
Explanation
A. "I am constipated." Constipation is not a common indicator of digoxin toxicity; it may be more related to diet or other medications.
B. "My vision seems yellow." Yellow or blurred vision, also called xanthopsia, is a classic sign of digoxin toxicity and should be reported immediately.
C. "My tongue is red and beefy." A red and beefy tongue may indicate vitamin B12 deficiency, not digoxin toxicity.
D. "I am gaining weight." Weight gain is usually a sign of fluid retention or worsening heart failure, not specifically digoxin toxicity.
Correct Answer is D
Explanation
A. "I will avoid crossing my legs at the knees." Crossing the legs can restrict blood flow and should be avoided in PVD.
B. "I will use a thermometer to check the temperature of my bath water." Due to reduced sensation, checking the water temperature can prevent burns.
C. "I will not go barefoot." Going barefoot increases the risk of injury or infection, especially with impaired circulation.
D. "I will wear stockings with elastic tops." Stockings with tight elastic tops can restrict blood flow, worsening symptoms in PVD.