The nurse is implementing the plan of care for a client.

For each body system, identify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention.

Each category must have at least one response option selected.

The correct answer is A. Ventilation, B. Neurological status, C. Exposure, F. Circulation.

Choice A: Ventilation Ventilation is a crucial part of the primary survey in trauma assessment. It involves assessing the patient’s respiratory rate and effort, use of accessory muscles, cyanosis, and chest wall movement. The normal respiratory rate for adults is between 12-20 breaths per minute.

Choice B: Neurological status Neurological status is another vital component of the primary survey. It often involves assessing the patient’s level of consciousness, often using tools like the Glasgow Coma Scale (GCS). The GCS score can range from 3 (completely unresponsive) to 15 (responsive).

Choice C: Exposure Exposure involves removing the patient’s clothing to check for any hidden injuries. It’s an essential step in trauma assessment, but there’s no “normal range” for this as it’s a process rather than a measurable variable.

Choice D: Current medications While knowing a patient’s current medications is important in managing their care, it’s not typically part of the primary survey in trauma assessment. This information is usually gathered during the secondary survey.

Choice E: Allergies Like current medications, information about allergies is also crucial in managing patient care, but it’s not part of the primary survey. This information is usually collected during the secondary survey.

Choice F: Circulation Circulation is a critical part of the primary survey. It involves checking the patient’s heart rate, blood pressure, capillary refill time, and looking for any signs of external bleeding. The normal resting heart rate can range between 60-99 beats per minute.

Choice A rationale
While it’s important to honor commitments, it’s also crucial to recognize when the caregiving role becomes too stressful or burdensome. Insisting on keeping a promise despite significant stress can lead to caregiver burnout.
Choice B rationale

This statement is not accurate. Moving a loved one into a care facility is sometimes the best decision for both the caregiver and the care recipient. It does not reflect a lack of love, but rather a recognition of the need for professional help.
Choice C rationale
This statement is not accurate. Caring for an adult, especially one with health issues, can be more challenging than raising a child in many ways.
Choice D rationale
Involving the care recipient in the decision-making process can help maintain their autonomy and dignity. It can also make the caregiving process more manageable.
Choice E rationale
It’s normal to have mixed feelings about a loved one for whom you’re providing care. Acknowledging these feelings can be an important step in managing caregiver stress.
Choice F rationale
This statement is not accurate. Setting boundaries is an important part of self-care and can help prevent caregiver burnout.
Choice G rationale
This statement is not accurate. Setting boundaries is an important part of self-care and can help prevent caregiver burnout.