The nurse employed in an emergency department is monitoring a ...

[codyclark]

The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating:
 
  1. Extreme fatigue
  2. The presence of pain
  3. An airway obstruction
  4. The presence of dehydration

Question 2

The client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on a thorough understanding of personality disorders, the nurse would select which nursing diagnosis as the priority?
 
  1. Ineffective coping
  2. Chronic low self-esteem
  3. Risk for self-mutilation
  4. Social isolation

[succesfull]

Answer to Question 1

3

Rationale: Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and sore throat. Extreme fatigue, the presence of pain, and the presence of de-hydration are inaccurate interpretations.

Answer to Question 2

3

Rationale: Clients with borderline personality disorder are most often hospitalized because of impulsive attempts at self-mutilation or suicide. The nursing intervention of constant close ob-servation is usually initiated to protect the client from impulsive behavior. Therefore, risk for self-mutilation is the priority.

[codyclark]

Thanks

[succesfull]

Welcome