The nurse is caring for an elderly client who fell down a flight ...

[LaDunn]

The nurse is caring for an elderly client who fell down a flight of stairs and experienced a closed head injury. Secondary to loss of respiratory drive caused by increased intracranial pressure, the client had a tracheostomy placed.
 
  When the daughter visits, she asks the nurse, Are you making sure Dad uses his CPAP at night? Because he has sleep apnea. What is the nurse's best response? 1. I will inform the doctor and get an order for respiratory therapy to set up a machine before bed tonight.
  2. He doesn't need his CPAP at night anymore, but I'll remind the doctor to order it just in case he has problems.
  3. CPAP was prescribed to keep the airway open. Now his tracheostomy will do that, and he won't need it until the tracheostomy is closed.
  4. When a client is critically ill and monitored on the cardiorespiratory monitor, he doesn't need his CPAP, because we'll know if he stops breathing.

Question 2

The 12 domains of culture developed by Purnell and Paulanka identify which of the following characteristics for the nurse to identify as part of developing cultural competence? Standard Text: Select all that apply.
 
  1. Communication
  2. Family roles
  3. Nutrition
  4. Death rituals
  5. Intelligence

[Bsand8]

Answer to Question 1

3
Rationale: When the airway becomes blocked while sleeping, the client stops breathing. The use of a CPAP machine helps to maintain an open airway. With a tracheostomy tube in place, the airway is no longer at risk for blockage, so he will not require a CPAP machine until the trach closes and he again breathes through his nose.

Answer to Question 2

1,2,3,4
Rationale 1: Communication, including dominant language and cultural communication patterns of the client

[LaDunn]

Thanks for the timely response, appreciate it

[debra928]

TYSM