The patient is brought to the emergency department complaining of severe shortness of breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient's respiratory status, the nurse should:
a. remove the patient's nail polish to get a pulse oximetry reading.
b. use a forehead probe to get a pulse oximetry reading.
c. use a finger probe to get a pulse oximetry reading.
d. check the color of the patient's nail polish before attempting a reading.
B
Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO2 (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish [Cieck et al., 2010]; medications such as bronchodilators).
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The parents of an 8-month-old infant are very distressed that the infant cries for at least one hour when they go out on Friday nights. Which of these statements should the nurse make to the parents?
1. "Your infant is too young to be experiencing stranger anxiety; however, you might need to stop going out on Friday nights for a while." 2. "Do you think your infant is in pain?" 3. "Oh, don't worry. All infants and toddlers display these behaviors until at least 2½ years old." 4. "Your infant is attached to you. This is an expected infant response."
The mother of a 20-year-old man diagnosed with paranoid schizophrenia is upset by the fact that her child tried to attack her during her daily visit. What is the most appropriate support the nurse can give her after this incident?
a. "Your child is working through relationship issues with you and does not know how to express them." b. "You should stop coming for a while, as your visits upset your child." c. "Your child's illness is due to a loss of contact with reality, and not directed to you as his mother." d. "You must make him realize that his behavior toward you is inappropriate."
Cancer of the vagina is rare and usually seen in women older than 40 years of age
Indicate whether the statement is true or false
Which assessment finding would support the nursing diagnosis of Acute Pain? Select all that apply
A) The client had an abdominal hysterectomy 1 day ago. B) The client is crying in pain about 20 minutes before her pain medicine is due. C) The client has a history of osteoarthritis. D) The client had back surgery 2 years ago and expresses the need for ibuprofen on most days. E) The client is a heavy cigarette smoker.