A patient's PaO2 level is 56 mm Hg. The nurse would plan care to prevent development of which condition?
1. Hypoxemia
2. Intrapulmonary shunt
3. Hypoxia
4. Hyperventilation
Answer: 3
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The client is admitted to rule out a diagnosis of non-Hodgkin's lymphoma. Which assessment finding best indicates to the nurse that an older adult client has non-Hodgkin's lymphoma?
1. Pitting edema bilaterally 2. Difficulty with walking 3. Severe bone pain in the lower back 4. Diffuse lymph node enlargement
A patient with Parkinson's disease would be at risk for falling as a result of:
1. quick movements. 2. unsteady, shuffling gait. 3. hemiparesis. 4. frequent loss of consciousness.
The burned client on admission is drooling and having difficulty swallowing. What is the nurse's best first action?
A. Assess level of consciousness and pupillary reactions. B. Ask the client at what time food or liquid was last consumed. C. Auscultate breath sounds over the trachea and mainstem bronchi. D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.
Which element of therapeutic environmental management has the highest priority?
a. Clearly establishing norms and designating limits b. Scheduling purposeful activities throughout the day c. Creating an environment of psychologic and physical safety d. Promoting a balance between patient dependence and independence