A patient has been admitted to the neurological unit from the PACU after successful neurosurgery to remove a brain tumor. The nurse's admitting assessment reveals that the patient's gag reflex has not yet fully returned
The nurse should recognize that this assessment finding has the potential to cause which of the following nursing diagnoses?
A) Risk for aspiration
B) Impaired spontaneous ventilation
C) Dysfunctional ventilator weaning response
D) Imbalanced nutrition: less than body requirements
A
You might also like to view...
The nurse taking care of a patient with a diagnosis of dissociative identity disorder is developing a plan of care. The nurse knows that which nursing diagnoses relate to the patient's diagnosis?
1. Nutrition, Impaired 2. Parenting, Impaired 3. Body Image, Disturbed 4. Pain, Related to violence
Which of the following helps the body release growth hormone (growth hormone assists in tissue regeneration, synthesis of bone, and formation of red blood cells)?
1) A healthy diet 2) Physical activity 3) Restful sleep 4) Comfortable room temperature
A patient has full-thickness burns of the right chest area, entire right arm, and deep partial-thickness burns of both upper anterior legs. Based on the rule of nines, which estimate of total body surface area burn would the nurse record?
1. 36% 2. 27% 3. 45% 4. 18%
Assessment of a pregnant client reveals that she is experiencing Braxton-Hicks contractions. Which of the following would the nurse explain is the cause of these contractions?
A) Uterine distention B) Fall in estrogen levels C) Prostaglandin release D) Catecholamine release