The client has a tracheostomy secondary to head and neck surgery. The nurse monitors the client for complications related to the absence of which important protective mechanism?
A)
Filtration and humidification of inspired air
B)
Decrease in oxygen-carrying capacity of the trachea
C)
The sneeze reflex initiated by irritants in the nasal passages
D)
The ability to cough
A
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Which of the following goals is appropriate for the nurse caring for an L1-L2 paraplegic undergoing rehabilitation?
A) Establishing an intermittent catheterization routine every 4 hours B) Managing spasticity with range-of-motion exercises and medications C) Establishing an ambulation program using short leg braces D) Preventing autonomic dysreflexia by preventing bowel impactions
The nurse documents episodes of echolalia when, after the nurse has asked a catatonic patient, "Where is your hat?" the patient:
a. excitedly says, "Hat, cat, rat, fat, scat, splat!" b. begins to cry and says, "I had a hat when my mother drove her yellow car." c. repeatedly says, "Your hat, your hat, your hat." d. places his hands on his head, saying, "Where is your hat?"
Which diabetic pt is at greatest risk for diabetic foot ulcer formation?
a. 75 yr old african-american male with history of cardiovascular disease b. 53 yr old caucasian female with history of renal insufficiency c. 38 yr old american indian with history of gastric ulcers d. 28 yr old caucasian male with history of chronic kidney disease
You complete your admission assessment and note the following abnormalities: B.K. is restless and alert,lying on her right side in a semifetal position
Assessment findings are as follows: skin is cool, diaphoretic, and pale with poor skin turgor; mucous membranes are dry. Heart rhythm is regular, rate 96, without murmurs or rubs. Peripheral pulses are faintly palpable in four extremities. Respiration rate 24, but unlabored on 2 L O 2/NC with spo2 90%. Breath sounds are absent in lower left lobe (LLL) posteriorly—otherwise, clear to auscultation throughout. she complains of nausea and is having dry heaves. Bowel sounds are hypoactive. Abdomen is distended, firm, and tender in a diffuse fashion to light palpation, with guarding noted. Your institution uses electronic charting. Based on the assessment given, which of the following systems would you mark as "abnormal" as you document your findings? Mark abnormal findings with an X and provide a brief narrative. X Abnormal ? Neurologic ? Respiratory ? Cardiovascular ? Gastrointestinal ? Genitourinary ? Musculoskeletal ? Skin ? Psychosocial ? Pain ? Neurologic: Restless and alert, lying on her right side in a semifetal position. ? Respiratory: Respirations rapid, rate 24, unlabored on 2 L O2/NC with Spo2 90%. Breath sounds are absent in LLL posteriorly. ? Cardiovascular: Peripheral pulses are faintly palpable in four extremities. ? GI: Complains of nausea; having dry heaves. Bowel sounds hypoactive. Abdomen distended, firm, and tender in a diffuse fashion to light palpation, with guarding noted. ? Genitourinary: ? Musculoskeletal: ? Skin: Skin cool, diaphoretic, and pale with poor skin turgor; mucous membranes are dry. ? Psychosocial: ? Pain: