The signs the nurse would expect to see in a patient with advanced emphysema are: (Select all that apply.)
a. productive cough.
b. dyspnea.
c. barrel chest.
d. wheezing.
e. cyanotic skin tone.
A, B, C, E
The emphysemic has a barrel chest and dyspnea. There is minimal coughing and mucus produc-tion until late in the disease. Wheezing usually does not occur in the emphysemic patient. Cya-nosis is usually absent until late in the disease when the patient becomes hypoxic.
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A school-age boy is in the emergency department with testicular torsion. Which action by the nurse takes priority for this patient?
A. Administer prophylactic antibiotics. B. Assess and treat the child's pain. C. Ensure surgical consent is on the chart. D. Ice and elevate the scrotum.
A client who is breastfeeding experiences engorgement on the 4th postpartum day. The nurse should explain to the client that engorgement is the result of:
a. a blocked milk duct b. milk stasis that has resulted in inflammation of the breast c. the breasts beginning to fill with colostrum d. vasocongestion of breast tissues as milk production begins
Which individual is most likely experiencing spiritual distress?
1) 75-year-old retired banker who spends his days fishing, biking, and golfing 2) 8-year-old child with chicken pox 3) 35-year-old mother of three with metastatic breast cancer 4) 12-year-old male recently diagnosed with appendicitis
Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the client is exhibiting signs of which of the following?
A) A dysrhythmia B) Tachycardia C) Bradycardia D) Hypertension