The nurse is caring for clients with spinal deformities. Which type of deformity would the nurse prioritize as having the most significant consequences on the respiratory system?
A) Kyphosis
B) Spinal fusion
C) Scoliosis
D) Lordosis
C
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Scoliosis is the lateral curvature of the spine that can impinge on the ability to expand the lungs. This inability can cause activity intolerance and respiratory compromise. Kyphosis is an exaggerated convex curvature of the thoracic spine. Lordosis is the excessive concave curvature of the lumbar spine. Spinal fusion is a surgical procedure to fuse two or more vertebrae together.
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A client admitted for trauma sustained while intoxicated has been hospitalized for 48 hours. He is
shaky, irritable, and anxious and tells of having vivid nightmares for 2 nights. An hour later, the nurse finds the client restless and perspiring. His pulse is 130 beats/min. He shouts "There are bugs crawling on my bed. I have got to get out of here," and begins to thrash about. The most accurate assessment of the situation would be the client a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. is having a recurrence of an acute psychosis. d. is demonstrating symptoms consistent with withdrawal delirium.
A patient tells a nurse that she is afraid of getting cervical cancer because her mother died of cervical cancer. What is the most appropriate response by the nurse?
a. "You need to a have a pelvic examination every 6 months because of your history." b. "If you have regular Pap smears, cervical cancer is usually diagnosed early and cured." c. "There's no need to worry so much. Cer-vical cancer does not run in families." d. "Cervical cancer is sexually transmitted. Don't switch partners often, and you don't have to worry."
After auscultating the aortic area, you determine that a patient has a diminished A2 and an ejection click. The most likely cause of these two findings is
a. arterial hypertension. b. aortic stenosis. c. the presence of an artificial aortic valve. d. ruptured chordae tendineae of the aortic valve.
Which of the following should the nurse keep in mind when writing goals and expected outcomes for a client?
a. A goal is a broad statement of desired changes that need not be written in behavioral terms. b. Goals focus on long-term needs, and expected outcomes focus on short-term needs. c. An expected outcome is a specific statement that describes the methods through which the goal will be achieved. d. Long-term goals focus on the etiology component of the nursing diagnosis.