The nurse is caring for an elderly client who fell down a flight of stairs and experienced a closed head injury. Secondary to loss of respiratory drive caused by increased intracranial pressure, the client had a tracheostomy placed
When the daughter visits, she asks the nurse, "Are you making sure Dad uses his CPAP at night? Because he has sleep apnea." What is the nurse's best response? 1. "I will inform the doctor and get an order for respiratory therapy to set up a machine before bed tonight."
2. "He doesn't need his CPAP at night anymore, but I'll remind the doctor to order it just in case he has problems."
3. "CPAP was prescribed to keep the airway open. Now his tracheostomy will do that, and he won't need it until the tracheostomy is closed."
4. "When a client is critically ill and monitored on the cardiorespiratory monitor, he doesn't need his CPAP, because we'll know if he stops breathing."
3
Rationale: When the airway becomes blocked while sleeping, the client stops breathing. The use of a CPAP machine helps to maintain an open airway. With a tracheostomy tube in place, the airway is no longer at risk for blockage, so he will not require a CPAP machine until the trach closes and he again breathes through his nose.
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A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). What should the ED nurse offer the patient? (Select all that apply.)
a. Privacy b. An opportunity to hold the infant c. Materials about support groups d. A memento (footprint or lock of hair) e. A warm beverage
You are the nurse who is collecting specific data related to risk factors, health indicators, and health outcomes that determine the burden of disease. What specific data would HALE yield about health indicators and outcomes?
A) Average number of years a newborn is expected to live if current mortality rates continue to apply. B) Average number of years that a person can expect to live in "full health" by taking into account years lived in less than full health due to disease and/or injury. C) Quantifying the burden of disease to a healthy life. The loss of years related to burden of disease. The gap in years reflects the current state of health versus an optimum state of health of a nation. D) Quantifying the burden of acute illness to a healthy life. The loss of years related to burden of acute illness. The gap in years reflects the current state of health versus an optimum state of health of a nation.
A client with bipolar disorder, manic phase, just sat down to watch television in the lounge. As the nurse approaches the lounge area, the client states, "The sun is shining. Where is my son? I love Lucy. Let's play ball." The client is displaying:
a) Concreteness. b) Flight of ideas. c) Depersonalization. d) Use of neologisms.
An older patient reports developing pneumonia easily; however, a spouse of the same age rarely "gets sick." How should the nurse respond?
A. "Not everyone's immune system is the same, regardless of their age." B. "It's just a matter of time. Your spouse will have the same illnesses you do." C. "Maybe your spouse just doesn't tell you about being sick." D. "Your spouse must be doing something that you're not doing."