The nurse is caring for a client who has no cough or gag reflex and is unable to take nutrients orally. Which device would be an appropriate choice for providing nutrition to this client?
1. A nasogastric tube
2. An orogastric tube
3. A nasoenteric tube
4. A jejunostomy tube
Correct Answer: 4
The client with an absent cough and gag reflex should not have an oral or nasal tube placed, because of the risk of aspiration. However, a jejunostomy tube would be a safe choice, because of the reduced risk of reflux into the esophagus.
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A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include:
a. aloofness, increased distractibility, and suspicion. b. elevated mood, hypertalkativeness, and distractibility. c. performing rituals and avoiding open places. d. darting eyes, distracted, and mumbling to self.
Which of the following does not encourage nursing presence?
1. "Thinking family" 2. Adequate nurse staffing 3. Time constraints 4. Human connections
Older children in a family who were present at a difficult birth may blame which of the following individuals for interfering or causing the problem?
a. Themselves c. Their fathers b. Their mothers d. The primary care giver
Vasopressors are used cautiously with critical care patients because they can cause
a. vasoconstriction of the smooth muscles. b. vasodilation of the smooth muscles. c. increased afterload of the heart. d. decreased preload of the heart.