Answer to Question 1
Correct Answer: 1
Rationale 1: Medications such as diazepam (Valium) can decrease the rate and depth of respirations. Older clients are at high risk of respiratory depression. The nurse must carefully monitor respiratory status in this client.
Rationale 2: Diazepam (Valium) does not affect urine output.
Rationale 3: Diazepam (Valium) does not affect muscle tone.
Rationale 4: Diazepam (Valium) does not affect appetite.
Answer to Question 2
Correct Answer: 4
Rationale 1: The alveoli do not respond to a low oxygen level.
Rationale 2: The trachea does not respond to a low oxygen level.
Rationale 3: The bronchioles do not respond to a low oxygen level.
Rationale 4: Special neural receptors sensitive to decreases in O2 concentration are located outside the central nervous system in the carotid bodies, just above the bifurcation of the common carotid arteries, and aortic bodies located above and below the aortic arch. Decreases in arterial oxygen concentrations stimulate these chemoreceptors, and they in turn stimulate the respiratory center to increase ventilation.
The nurse conducts the health history as the first step in the nursing assessment
Magnet hospital nurse requirements
To check pupillary reflexes the nurse first holds the penlight
Example of simplified note for one-time client.
Building a Client Base Cont.