Vital Signs Nursing: Trivia Quiz!

Dyspnea is related to inadequate oxygenation, meaning the client will most likely experience shortness of breath. Shallow respirations are associated with tachypnea (rapid breathing). Wheezing may or may not occur with dyspnea. Hemoptysis is unrelated to dyspnea.

Imbalanced nutrition: more than body requirements is the most appropriate nursing diagnosis for a client with a BMI of 35. This diagnosis indicates that the client is consuming more calories than their body needs, leading to weight gain and an increased risk for obesity-related health problems. The client's high BMI suggests that they may be overeating or making poor food choices, contributing to the imbalance in their nutrition. By identifying this diagnosis, nurses can develop interventions to help the client make healthier dietary choices and manage their weight effectively.

Automobile crashes are the leading cause of accidents in young and middle-aged adults. This is because young and middle-aged adults are more likely to be active drivers and spend a significant amount of time on the roads. Factors such as inexperience, distracted driving, speeding, and impaired driving contribute to a higher risk of accidents in this age group. Additionally, the use of mobile devices while driving has become increasingly common among young and middle-aged adults, further increasing the likelihood of automobile crashes.

Before inserting the client's hearing aid, it is important to turn the hearing aid off. This is necessary to prevent any discomfort or potential harm to the client's ear when the hearing aid is being inserted. Turning off the hearing aid ensures that it is not accidentally turned on during the insertion process, which could cause discomfort or loud noises for the client.

Increasing exercise by at least 30 minutes each day is a healthy approach to desired weight loss. Exercise helps to burn calories and increase metabolism, which can aid in weight loss. It also has numerous other health benefits, such as improving cardiovascular health, increasing muscle strength, and boosting mood. Switching to a low carb diet may be effective for weight loss in some cases, but it is not specified if the individual's current diet is high in carbs. Keeping a list of forbidden foods may lead to a restrictive mindset and potential disordered eating patterns. Buying more organic and less processed foods can be a healthy choice, but it alone may not lead to significant weight loss.

Repeatedly ignoring the sensation of needing to defecate can lead to constipation. When individuals consistently ignore the urge to have a bowel movement, the stool can become dry and hard, making it difficult to pass. This can result in infrequent or incomplete bowel movements, causing discomfort and bloating. Therefore, it is important for clients to be aware of the importance of responding to the body's natural signals and not ignoring the need to defecate.

the apical pulse would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm.

walking barefoot increases the chance for injury and infection

deflation should occur at 2-3 mm Hg per second, so previous start would have been 168 (30+138) and going down at a rate of 2-3 seconds.

The proper technique with gravity tube feeding is to hang the feeding bag 1 ft higher than the tube's insertion point into the chest. This ensures a continuous flow of the feeding solution into the patient's stomach or intestines. Gravity helps in the proper flow of the feeding solution and prevents any backflow or blockage in the tube. Hanging the bag higher than the insertion point creates a pressure gradient that facilitates the flow of the solution.

Using a non-perfumed lotion is the correct answer because it helps to moisturize the skin and prevent dryness. Perfumed lotions may contain irritants that can further dry out the skin, so it is important to use a non-perfumed option. Soaking the feet frequently can actually worsen dryness by stripping away natural oils. Applying foot powder may help with odor, but it does not address the issue of dry skin. Avoiding knee high elastic stockings is not directly related to maintaining intact skin on the feet and lower extremities.

Semisoft tar-colored stools are most likely to validate that a client is experiencing intestinal bleeding. Intestinal bleeding can cause the stool to appear black and tarry, indicating the presence of digested blood. This stool color is often associated with bleeding in the upper gastrointestinal tract, such as the stomach or small intestine. It is important to note that the other options do not typically indicate intestinal bleeding. Large quantities of fat mixed with pale yellow liquid stool may suggest malabsorption or pancreatic issues, brown, formed stools are considered normal, and narrow, pencil-shaped stools may indicate a potential obstruction in the colon.

The most appropriate safety measure for a 75-year-old client who becomes disoriented and tries to get out of bed is to use a bed exit safety monitoring device. This device will help alert the healthcare team if the client attempts to leave the bed without assistance, allowing them to intervene and prevent falls or injuries. Restraints should be avoided whenever possible due to the risk of physical and psychological harm. Asking a family member to stay with the client may not be feasible or available at all times, and checking the client every 15 minutes may not provide immediate intervention if the client attempts to leave the bed.

placing bed in the lowest position makes the fall shorter

Although the temp is slightly lower than expected, it would be best to determine the client's previous temp range next. This may be normal for the client.

Vital signs may be delegated if they are stable, the findings are expected or the technique requires no modification.

When planning to teach health care topics to a group of male adolescents, the nurse should consider that guns are the most frequently used weapon in adolescent suicide. This topic takes priority because it addresses a serious and immediate health concern for this specific population. By providing education and raising awareness about the dangers of guns and the risk of suicide, the nurse can potentially help prevent tragic outcomes and promote the overall well-being of these adolescents.

The client is able to perform most activities of daily living independently, such as bathing, walking, and dressing. However, they require assistance with bathing their back and feet, indicating a level of dependency in those areas. Therefore, the most appropriate functional level for this client is semidependent (+2).

The nurse observed the UAP performing perineal care for a client and noticed that they did not retract the foreskin. This indicates that further teaching is required because retracting the foreskin is an important step in perineal care for male clients. It allows for proper cleaning and inspection of the area, ensuring hygiene and identifying any potential issues or abnormalities. Therefore, the UAP should be educated on the importance of retracting the foreskin during perineal care.

Ok - oral + stroke + facial dropping = no. Rectal would work but that's wayyy to much extra work when you have other methods.

see K+E pg. 689

The client is experiencing labored, shortness of breath and has a respiratory rate of 28. Placing the bed in Fowler's position would be the best nursing intervention. Fowler's position is a semi-sitting position with the head of the bed elevated between 45 and 60 degrees. This position helps to improve lung expansion and ease breathing by allowing the diaphragm to descend more easily. It also helps to prevent aspiration and promotes drainage in patients with conditions such as pneumonia or congestive heart failure.

Since the client's needs always come first, delay the measurement unless it looks urgent.

The pH of the aspirate being less than 5 is the best indication of proper placement of a nasogastric tube in the stomach. A pH of less than 5 indicates that the tube is in the acidic environment of the stomach, confirming correct placement. The other options, such as the client being unable to speak or gagging during insertion, are not reliable indicators of proper placement. Additionally, the ease of fluid instillation into the tube does not necessarily indicate correct placement.

The statement "I need to take a laxative such as milk of magnesia if I don't have a BM each day" provides evidence that the older adult may need more education on managing constipation. This statement suggests that the individual believes that taking a laxative is necessary for daily bowel movements, which may indicate a lack of understanding about natural bowel patterns and the importance of dietary and lifestyle changes in promoting regular bowel movements.

the catheter can not be reused. Leaving the old on in place will help differentiate vaginal opening from the urinary meatus

The nurse is most likely to report that the stoma color is deep purple because this could indicate a lack of blood supply to the stoma, which is a serious concern. A healthy stoma should be pink or red, so a deep purple color suggests ischemia or necrosis. This finding should be reported to the primary care physician immediately for further evaluation and intervention.

The nursing diagnosis "Risk for poisoning" is the most applicable for toddlers because they are at a stage where they are curious and exploring their environment, which puts them at a higher risk for accidental ingestion of harmful substances. Toddlers have a tendency to put objects in their mouths, and they may not have developed the ability to differentiate between safe and dangerous substances. Therefore, the risk for poisoning is a significant concern for this age group.

A Kock (pronounced coke) pouch creates a conduit to the bladder using a portion of the ileum to form a reservoir for urine. Client needs to place catheter @ home. CISC requires medical aspesis.

The client is in surgery and will be returning to his bed via a stretcher. In order to accommodate the client's needs and ensure a smooth transition, the nurse plans ahead by making a surgical bed in high position. This allows for easy access and transfer of the client from the stretcher to the bed.

The appropriate nursing management of a client wearing a condom catheter includes checking the penis for adequate circulation after 30 minutes. This is important to ensure that the condom catheter is not causing any restriction in blood flow to the penis, which could lead to complications such as tissue damage or necrosis. Regular checks for circulation help to prevent these complications and ensure the client's safety and well-being.

Soaking increases the possible spreading of infection

The adult's daily intake of dairy, fruit, and meat is within the recommended range. However, the intake of grains is below the recommended amount of 6 ounces per day. Therefore, the nurse would advise increasing the number of servings of grains to ensure a balanced diet.

In the event of a fire in a health setting, the first priority should be to protect the clients by ensuring their safety and evacuating them if necessary. Once the clients are safe, the nurse should then report the fire to the appropriate authorities or fire department. After reporting the fire, the nurse should focus on containing the fire to prevent it from spreading further and causing more damage. Finally, if it is safe to do so, the nurse can attempt to extinguish the fire using appropriate fire-fighting equipment. Therefore, the correct sequence of nurse priorities in this situation is 3, 2, 4, 1.

The meal consisting of 3 ounces of tuna, a 1 ounce cheese sandwich on whole wheat bread, and a pear would be recommended by the nurse as the highest in calcium, iron, and fiber. Tuna is a good source of both calcium and iron, while the cheese sandwich on whole wheat bread provides additional calcium and fiber. The pear adds more fiber to the meal, making it the best choice for all three nutrients. The other meal options do not contain as much calcium, iron, and fiber as this choice.

Antihistamines can increase urine output

The nurse plans the client's meal based on the need to include as many of the client's favorite foods as possible. This is because the client has mild dysphagia from a recent stroke, which may make swallowing difficult. By including the client's favorite foods, the nurse can ensure that the client enjoys their meal and is more likely to eat an adequate amount. This is important for maintaining proper nutrition and preventing malnourishment in elderly clients.

Don't give meds or interventions without an order. Right?

As people age, their bladder muscles may weaken, leading to incomplete emptying of the bladder. This can cause a larger amount of urine to be retained after voiding. This is why the nurse recognizes that urinary elimination changes may occur even in healthy elders. The other options are not relevant in explaining this phenomenon.

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The given answer, "return flow enema," is correct because the client's symptoms of a firm, distended abdomen, pain on palpation, and feeling bloated indicate the presence of gas or fecal impaction. A return flow enema is designed to help relieve these symptoms by introducing fluid into the rectum and then allowing it to flow back out, carrying any gas or fecal matter with it. This type of enema helps to relieve discomfort and promote bowel movement.

high volume enema could result in electrolyte imbalance that makes it less than ideal.

The client with a flaccid bladder is likely to have difficulty emptying their bladder completely. The Credes Maneuver involves applying gentle manual pressure to the lower abdomen to help promote bladder emptying by manually compressing the bladder. This technique can be taught by the nurse to help the client effectively empty their bladder and prevent complications such as urinary retention or urinary tract infections. Habit training, bladder training, and Kegel exercises may not be as effective in this situation as they do not directly address the issue of bladder emptying.