The nurse has chosen the nursing diagnosis Ineffective Breathing for a patient with muscular dystrophy. Which interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Assess the gag reflex before administering food or fluids.
2. Encourage frequent rest periods during daily activities.
3. Teach pursed-lip breathing.
4. Assess capillary refill.
5. Observe for use of accessory muscles.
2,3,5
Rationale 1: The gag reflex is associated with Risk for Aspiration.
Rationale 2: Frequent rest periods are needed to facilitate respiration.
Rationale 3: Pursed-lip breathing helps to expand lungs for maximum oxygen intake and helps expel carbon dioxide.
Rationale 4: Capillary refill is related to tissue perfusion and cardiac output.
Rationale 5: The use of accessory muscles indicates respiratory dysfunction.
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A patient tells a nurse that she recently lost her job and that ever since, she has been going home and verbally abusing her spouse and child. The patient has lost all of her friends and feels confused. This patient is presenting the defense mechanism of
1. Repression. 2. Displacement. 3. Conversion. 4. Restitution.
The nurse is assessing a client who has undergone a transurethral resection of the prostate (TURP). Which assessment finding requires immediate action by the nurse?
a. Passing small blood clots after catheter removal b. Experiencing urinary frequency after ca-theter removal c. Having bright red drainage with multiple blood clots d. Having the urge to void continuously while the catheter is inserted
Vascular dementia is often referred to as:
a. multi-infarct dementia b. hypertensive dementia c. brain dementia d. dementia of circulation