The nurse assesses a patient's respirations who was recently admitted with a traumatic head injury. The nurse expects to find which type of breathing during the assessment?
a. Apneustic respiration
b. Cheyne-Stokes
c. Kussmaul's
d. Biot's
D
Biot's respirations are characterized by irregular periods of apnea followed by four to five breaths of identical depth. This pattern is associated with increased intracranial pressure, which is common with a traumatic head injury. Apneustic respirations are indicative of damage to the respiratory centers in the brain. Cheyne-Stokes respirations are often seen in patients in a coma resulting from a disorder affecting the central nervous system. Kussmaul's respiration is an ab-normal breathing pattern often seen in patients with diabetic acidosis and coma.
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A client's morning glucose level is 46%. The facility has an order approved by a health care provider that states, "The nurse will administer 6 ounces of orange juice and repeat the glucose level in 30 minutes if below 60"
This type of standardized intervention is known as what type of order? a. emergency c. specific b. health care provider d. standing
The nurse is performing an abdominal assessment. After percussing the abdomen, the nurse notes that the liver span is approximately 9 centimeters. Which of the following ways is an appropriate way to document this finding?
1. Hepatomegaly 2. A normal finding 3. Related to recent diagnosis of chronic bronchitis 4. Presence of ascites
The nurse is conducting a thorough psychosocial assessment of a client who presents with complaints of fatigue, tearfulness, and relationship difficulties. What action by the nurse would support accurate assessment?
1. Take detailed notes to record client responses. 2. Ask as many questions as possible to explore all areas of concern. 3. Start the interview by asking a series of yes/no questions. 4. Investigate the client's culture prior to the interview.
The nurse's knowledge about spirituality begins with the nurse:
A) looking at his or her own beliefs B) researching all popular religions C) sharing his or her faith with the patients D) providing prayers and religious articles for patients