A nurse is caring for a client with chronic renal failure who has developed severe metabolic acidosis. What assessment finding would be expected in this client?
A. Hyperventilation
B. Bradycardia
C. Hypotension
D. Seizures
A
With severe metabolic acidosis, the client will develop hyperventilation, or Kussmaul respiration.
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A client diagnosed with major NCD is exhibiting behavioral problems on a daily basis. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Which action should be a nursing priority?
1. Consult the psychologist regarding behavior-modification techniques. 2. Medicate the client with prn antianxiety medications. 3. Assess environmental triggers and potential unmet needs. 4. Anticipate the behavior and restrain when pacing begins.
A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?
1) Partial-thickness wound 2) Penetrating wound 3) Superficial wound 4) Full-thickness wound
The cystic fibrosis patient furiously refuses any more manual chest physiotherapy. The nurse could suggest which alternative?
1. Flutter mucus device 2. Increase ambulation to 1 to 2 hours/day 3. Steam inhalator several times a day 4. Drinking 3 quarts of fluid per day
The only drug used for skeletal muscle relaxation that does not affect the central nervous system is:
a. dantrolene. b. baclofen. c. diazepam. d. tizanidine.