The nurse is caring for an elderly client who is having difficulty raising secretions in order to clear her airway. The nurse understands that which of the following conditions likely affects this client's ability to clear her airway?
A) Reduced air exchange
B) Exposure to airborne toxins
C) Reduced efficiency in ventilation
D) Atrophy of the larynx
D
Feedback:
The nurse should understand that the muscular structures of the larynx tend to atrophy with age, which can affect the ability to clear the airway in the elderly client. Reduced air exchange and efficiency in ventilation are the primary age-related changes affecting the older adult's respiratory system, but these do not directly affect the ability to mobilize secretions. Exposure to airborne toxins leads to pathologic pulmonary changes.
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a. Peripheral neuropathy b. Chronic stable depression c. Intertrochanteric fracture d. Opioid analgesic addiction
The nurse is completing an admission assessment. The assessment form allows for the separation of subjective and objective data. Distinguish which of the following are examples of subjective data utilized by the nurse
Standard Text: Select all that apply. 1. The client's mother informs the nurse that her daughter has not been sleeping due to pain. 2. The client states, "I have pain in my belly that is 7 out of 10." 3. Abdominal assessment reveals a firm, hard abdomen. 4. The client is weak and looks very pale. 5. The client appears nervous during the data collection period.
Nursing assessment of a client who has been diagnosed with neuroleptic malignant syndrome (NMS) would most likely reveal what?
A) Chest pain, tachycardia, and cardiac dysrhythmias B) Respiratory distress, cyanosis, and pallor C) Nausea, vomiting, diarrhea, and gastric pain D) Hyperpyrexia, severe hypertension, and diaphoresis
The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the client's skin integrity?
1. Having the client sit up in a chair for 4-hour intervals 2. Keeping the head of the bed in a high-Fowler's position to increase circulation 3. Keeping a written schedule of turning and positioning 4. Encouraging the client to perform pelvic muscle training exercises several times a day