The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving mechanical ventilation. Which intervention is a priority for this client?
a. Administering antibiotics every 6 hours
b. Positioning the client with the "good lung dependent"
c. Making sure that the pilot balloon line on the endotracheal tube is deflated
d. Ensuring that the client is able to speak clearly
B
Clients who are being mechanically ventilated are experiencing a problem in that their normal ventilation is not adequate. The recommended position for clients who have one lung more af-fected by a problem than the other lung is to place the "good lung down," keeping the healthier lung dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung, thus helping a ventila-tion/perfusion mismatch. Antibiotics are not prescribed for this disorder. The pilot balloon line should be inflated to ensure that the cuff is inflated, keeping the endotracheal tube in place and directing ventilated air into the lungs. The client with an endotracheal tube that is nonfenestrated, with the cuff inflated, will not be able to speak. Communication is addressed in other ways.
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The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia?
a. Global b. Broca's c. Dysphonic d. Wernicke's
A nurse is assessing a patient who is suspected of having bronchiectasis. The nurse should consider which of the following potential causes? Select all that apply
A) Pulmonary hypertension B) Airway obstruction C) Pulmonary infections D) Genetic disorders E) Atelectasis
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a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) often is visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).
An abuser finds many rewards from abusing someone weaker. What is one reward?
A. Recognition for fulfilling role expectations B. The admiration by others of the good behaviors of family members C. The appreciation of others who admire true leaders of the family D. The victim works very hard to be attentive, to be nurturing, and to placate the abuser.