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The nurse assesses distended neck veins in a patient sitting in a chair to eat.Which is the priority intervention of the nurse?
A) Document the observation in the chart.
B) Assess the patient's deep tendon reflexes.
C) Measure urine specific gravity and volume.
D) Check the patient's pulse and blood pressure.
Distended Neck Veins
The visible swelling or bulging of neck veins, often indicative of cardiovascular problems or increased pressure in the chest.
Deep Tendon Reflexes
Neurological responses elicited by tapping specific tendons with a reflex hammer to assess the central and peripheral nervous system's integrity.
Specific Gravity
A measure of the density of a substance compared to the density of water, indicating concentration.
- Conduct precise evaluations of patients to detect significant variations in their health status.
- Determine and implement suitable treatment options for patients experiencing reduced cardiac output.
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Learning Objectives
- Conduct precise evaluations of patients to detect significant variations in their health status.
- Determine and implement suitable treatment options for patients experiencing reduced cardiac output.
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