The nurse measures a client's respiratory rate at 34 rpm. The nurse reviews the client's chart and discovers the following factors that might be causing the increase in respirations: Standard Text: Select all that apply
1. The client is febrile.
2. The client was just told about a poor prognosis.
3. The client has been diagnosed with increased intracranial pressure.
4. The client was just medicated for pain.
5. The client's body temperature is 96°F.
1,2
Rationale: The client who is febrile will often have an increased respiratory rate.
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All of the following statements are true regarding tuberculosis (TB) except
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The nurse is providing care for a patient who is in shock after massive blood loss from a workplace injury
The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states? A) Third spacing of fluid B) Dysrhythmias C) Tachycardia D) Gastric hypermotility
The nurse is caring for a term infant born with a congenital diaphragmatic hernia. The nurse's assessment reveals respiratory distress, as evidenced by presence of cyanosis, ineffective breathing pattern and diminished breath sounds
The realizes that the infant requires ventilatory support. The nurse positions the infant on left side with the head of bed elevated. What is the rationale for the nurse's action? a. The parents prefer the infant's head to be elevated. b. Optimizes gas exchange of unaffected lung and helps to encourage down- ward displacement of the abdominal contents. c. The infant prefers sleeping on the left side. d. Provides reverse circulation so that fluids leave the lower extremities and return to the heart.
A 4-year-old boy is hospitalized with a serious bacterial infection. He tells the nurse that he is sick because he was "bad." What is the nurse's best interpretation of this comment?
a. Sign of stress b. Common at this age c. Suggestive of maladaptation d. Suggestive of excessive discipline at home