What will the nurse assess in a patient experiencing the fibrotic phase of acute lung injury?
1. Pulmonary occlusive pressures are less than 18 mm Hg.
2. Bilateral fluid can be seen on radiographic exams.
3. Severe bleeding is noted from all body orifices.
4. Fever and leukocytosis are present.
4
Rationale 1: This is not an assessment finding in the fibrotic phase of acute lung injury.
Rationale 2: This is not an assessment finding in the fibrotic phase of acute lung injury.
Rationale 3: This is not an assessment finding in the fibrotic phase of acute lung injury.
Rationale 4: During the fibrotic phase (the final phase) there is altered healing that results from the development of fibrotic tissue in the alveolar capillary membrane. This disfigurement contributes to the decrease in lung compliance and worsening pulmonary hypertension; leukocytosis, continuing infiltrates, and fever occur.
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A client who is experiencing a low calcium level is being assessed for the possibility of an alteration in the function of the parathyroid. When the levels of PTH reveal a low level, the nurse should tell the client:
1. the problem is due to problems in the thyroid gland. 2. the adrenal glands are not functioning appropriately. 3. the secretion of PTH is dependent on normal levels of vitamin D. 4. the client should increase phosphorous intake.
Diagnosing is considered to be in which step of the nursing process?
a. first c. third b. second d. fourth
Which client response should a nurse expect during the working phase of the nurse–client relationship?
A. The client gains insight and incorporates alternative behaviors. B. The client and nurse establish rapport and mutually develop treatment goals. C. The client explores feelings related to reentering the community. D. The client explores personal strengths and weaknesses that impact behaviors.
The nurse is performing an assessment on a client who has been taking a tricyclic antidepressant for several weeks. Which common adverse effect of tricyclic antidepressants is most likely to occur?
1. Dry mouth 2. Bradycardia 3. Sedation 4. Orthostatic hypotension