Author Question: A trauma client has experienced a ruptured diaphragm. The nurse would anticipate that this client ... (Read 63 times)

Themember4 · **on:** Jul 23, 2018

A trauma client has experienced a ruptured diaphragm. The nurse would anticipate that this client will have difficulty:

1. with an elevated oxygen level.
2. primarily during exhalation.
3. maintaining a high enough respiratory rate.
4. carrying out the respiratory cycle.

Question 2

The father of a 3-year-old states, He isn't current on his immunizations. I have full custody of him now, but I don't know what he needs. Which nursing diagnoses would the nurse choose for this situation?

Standard Text: Select all that apply.
1. Caregiver Role Strain
2. Coping, Ineffective
3. Knowledge, Deficient
4. Health Maintenance, Ineffective

Natalie4ever · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 4
Rationale 1: The oxygen level would be low because of inadequate ventilation.
Rationale 2: Both inhalation and exhalation would be impaired.
Rationale 3: The client's chest will be unable to move adequately, and the respiratory rate will increase in an effort to increase oxygenation.
Rationale 4: Contraction and relaxation of the diaphragm are essential to the ventilation segment of the respiratory cycle.
Global Rationale: Ventilation is the process of moving air into and out of the lungs. As the diaphragm contracts and lowers in position, it creates a negative pressure that draws air into the lungs and inspiration occurs. During expiration the diaphragm relaxes and air leaves the lungs passively. The oxygen level would be low because of inadequate ventilation. Both inhalation and exhalation would be impaired. The client's chest will be unable to move adequately, and the respiratory rate will increase in an effort to increase oxygenation.

Answer to Question 2

Correct Answer: 3, 4
Rationale 1: There is no evidence that this father has Caregiver Role Strain.
Rationale 2: There is no evidence of Ineffective Coping in this situation.
Rationale 3: The father admits that he does not know which immunizations are required.
Rationale 4: The child currently has this risk but will soon drop this diagnosis as immunizations are brought up to date.
Global Rationale: Common nursing diagnoses associated with immunization include Deficient Knowledge (Vaccination Schedule, recommendations), Ineffective Health Maintenance, related to failure to complete immunization schedule, and Risk for Injury, related to adverse drug effects. There is no evidence of Caregiver Role Strain or Ineffective Coping.