A client is diagnosed with organic brain disorder. The nursing care should include:
Answer(s): A
(A) A priority nursing goal is attending to the client's safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, frequent visits are recommended to avoid overstimulation and fatigue. (C) Short, concise, simple Explanation are easier to understand. (D) Mental capability and attention span deficits make learning difficult and frustrating.
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:
Answer(s): C
(A) The fourth stage begins after expulsion of the placenta. Client symptoms are: fatigue; chills; scant, bloody vaginal discharge; and nausea. (B) The third stage is from birth to expulsion of placenta. Client symptoms are uterine contractions, gush of blood, and perineal pain. (C) The transition stage is characterized by strong uterine contractions and cervical dilation. Clientsymptoms are irritability, restlessness, belching, muscle tremors, nausea, and vomiting. (D) The second stage is characterized by full dilation of cervix. Client symptoms are perineal bulge, pushing with contractions, great irritability, and leg cramps.
A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side.The nurse identifies the most likely cause of this as:
(A) Appropriate endotracheal tube sizes for adults range from 7.08.5 mm. (B) Pneumothorax could be indicated by an absence of breath sounds on the affected side. However, in a recently intubated client, the first priority would be to consider tube malposition. (C) During intubation, the right mainstem bronchus can be inadvertently entered if the endotracheal tube is inserted too far. Left mainstem bronchus intubation almost never occurs because of the angle of the left mainstem bronchus. (D) Breath sounds for someone with pneumonia may be decreased over the areas of consolidation. However, in a recently intubated client, the first priority would be to consider tube malposition.
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