Answer to Question 1
C
Feedback:
Because of the patient's age and that the medication causes sedation, the highest priority nursing diagnosis is related to maintaining the patient's safety. Safety for the patient is the nurse's number one concern. There is nothing indicated related to the cost of the drug or the risk of noncompliance for this patient. Deficient knowledge will need to be addressed but it is not the priority when compared with patient safety. There is no indication the patient's need for this medication is related to an ineffective health maintenance issue.
Answer to Question 2
C
Feedback:
ARDS is characterized by progressive loss of lung compliance and increasing hypoxia and occurs as a result of a severe insult to the body. Accumulation of copious amounts of thick secretions in the lungs is associated with cystic fibrosis. Chronic obstructive pulmonary disease (COPD) is characterized by loss of the elastic tissue of the lung, destruction of alveolar walls, and hyperinflation with tendency to collapse with expiration. Reversible bronchospasm, inflammation, and hyperactive airways are characteristics of asthma.
Patient teaching: hair and scalp assessment
Bilateral psoriasis on a patient’s knees.
Foley catheter with balloon in the bladder of a male patient.
Calipers being used to measure body fat on the triceps of a patient.
Patient Physical Status Classification
Effectiveness of Drug Therapy