_____37. One оf the mаjоr pillаrs оf the positive psychology movement involves the study of
Where dоes the brаchiаl аrtery bifurcate intо the radial and ulnar arteries ?
The nurse is cаring fоr а 25-yeаr-оld male in the EDNursing Nоtes1400 - To the ED after a branding accident where a bull escaped and pinned the client against a metal fence for approximately 60 seconds. The bull’s horn penetrated his right eye, causing the loss of the eyeball (globe), leaving an empty orbital cavity. Breathing is labored. He is conscious but in visible pain and distress. Initial primary assessment:Airway – patent, 2 missing teeth, some other teeth are loose. The client is spitting out bloody secretions.Breathing – RR = 32 shallow breaths/min, pulse ox 84% on RA, asymmetrical chest movement, left side rises while the right side moves downward with inspiration.Circulation – BP 172/94 mm/Hg, HR 126 beats/minute, sinus tachycardia. Pulse 2+ in all extremities. Cap refill 3 seconds. Skin is warm but pale.Disability – A&O x2 (person & place), GSC = 13, pupils round at 3mm and reactive in the left eye. Unknown whereabouts of the right eye.Exposure – Clothing removed and warming lights and blankets applied. Empty orbital cavity of the right eye with significant soft tissue damage. Pain rating 10/10 in “face and chest.” Multiple contusions and abrasions on the chest and throughout the body. No visible orthopedic extremities or hip deformities.1415 - Bedside ultrasound completed, diagnosis of multiple rib fractures, pneumothorax, flail chest, and a traumatic right globe loss.1420 – Health Care Provider OrdersHigh-flow oxygenIV Lactated Ringer at 150 ml/hr IVDilaudid 2 mg IVPHead, chest, abdomen, pelvis, CT scanNeuro checks q 15 minutesCover the right orbital cavity with a sterile dressingCephalexin 1 gram IVPrepare for a chest tube1436 - A 20 French chest tube was inserted per HCP and attached to the drainage device. Continuous bubbling and tidaling are observed.The nurse has performed the interventions as ordered by the healthcare provider. For each client assessment finding, click to specify if the finding indicates the client’s condition has improved, has not changed, or has declined.ImprovedNo changeDeclinedRR 28 breaths/minuteBP 192/68 mm/HgHR 145 beats/minuteAsymmetrical chest movementBloody secretionsGlasgow Coma Scale (GCS) 14Pulse 1+ in lower extremities
The nurse is cаring fоr а 25-yeаr-оld male in the EDNursing Nоtes1400 - To the ED after a branding accident where a bull escaped and pinned the client against a metal fence for approximately 60 seconds. The bull’s horn penetrated his right eye, causing the loss of the eyeball (globe), leaving an empty orbital cavity. Breathing is labored. He is conscious but in visible pain and distress. Initial primary assessment:Airway – patent, 2 missing teeth, some other teeth are loose. The client is spitting out bloody secretions.Breathing – RR = 32 shallow breaths/min, pulse ox 84% on RA, asymmetrical chest movement, left side rises while the right side moves downward with inspiration.Circulation – BP 172/94 mm/Hg, HR 126 beats/minute, sinus tachycardia. Pulse 2+ in all extremities. Cap refill 3 seconds. Skin is warm but pale.Disability – A&O x2 (person & place), GSC = 13, pupils round at 3mm and reactive in the left eye. Unknown whereabouts of the right eye.Exposure – Clothing removed and warming lights and blankets applied. Empty orbital cavity of the right eye with significant soft tissue damage. Pain rating 10/10 in “face and chest.” Multiple contusions and abrasions on the chest and throughout the body. No visible orthopedic extremities or hip deformities.1415 - Bedside ultrasound completed, diagnosis of multiple rib fractures, pneumothorax, flail chest, and a traumatic right globe loss.1420 – Health Care Provider OrdersHigh-flow oxygenIV Lactated Ringer at 150 ml/hr IVDilaudid 2 mg IVPHead, chest, abdomen, pelvis, CT scanNeuro checks q 15 minutesCover the right orbital cavity with a sterile dressingCephalexin 1 gram IVPrepare for a chest tubeAfter reviewing the healthcare provider's orders. What 2 orders should the nurse perform immediately?