The nurse observes a patient us accessory muscles while walking for the first time after hip surgery. Which muscles are commonly used in respiration during exercise or strenuous activity? (Select all that apply.)
a. Scalene
b. Diaphragm
c. Abdominal
d. Vastus lateralis
e. Intercostal muscles
f. Sternocleidomastoid
ANS: A, B, C, E, F
Accessory muscles of respiration are used during exercise and times of respiratory distress; these include the sternocleidomastoid and scalene muscles and abdominal musculature. The diaphragm and intercostal muscles are used in normal respiration and during activity. D. The vastus lateralis is in the leg.
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The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?
a. Woman in her second month of pregnancy b. Person who has been on bed rest for 4 days c. Person with a 30-year, 1 pack per day smoking habit d. Older adult taking anticoagulant medication
The nurse is administering intramuscular glucagon to a diabetic client who is hypoglycemic and unable to swallow. Which precaution should the nurse institute for complications or res-ponses to this therapy?
A. Apply pressure to the injection site for 5 minutes. B. Position the client on his or her side. C. Have a padded tongue blade available. D. Elevate the head of the bed.
Which is a clinical manifestation of acetaminophen poisoning?
a. Hyperpyrexia b. Hepatic involvement c. Severe burning pain in stomach d. Drooling and inability to clear secretions
The phase of the discharge process where medical attention dominates discharge planning efforts is known as:
a. The transitional phase b. The continuing phase c. The acute phase d. The multidisciplinary phase