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Patient Data

Exhibits

According to the client's vital signs, he is experiencing

 and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Tachypnea refers to abnormally rapid breathing, characterized by an increased respiratory rate. In adults, tachypnea is typically defined as a respiratory rate above 20 breaths per minute at rest.

Tachycardia is a medical condition characterized by a rapid heart rate, typically above 100 beats per minute in adults at rest.

Eupnea refers to normal, unlabored breathing at a normal rate and depth. It is characterized by regular inhalations and exhalations without any signs of respiratory distress or abnormalities.

Hypothermia is a medical condition characterized by an abnormally low body temperature, typically below 95°F (35°C).

Bradycardia is a medical condition characterized by an abnormally slow heart rate, typically below 60 beats per minute in adults.

Hyperthermia is a medical condition characterized by an abnormally high body temperature, typically above 100.4°F (38°C).


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Related Questions

Correct Answer is B

Explanation

B. Aspiration can lead to serious respiratory complications such as pneumonia. Since the client reports difficulty swallowing (dysphagia) and has a high pain level, addressing the risk for aspiration is crucial to prevent further complications.

A. While nutrition is essential for overall health, it may not be the priority in this case given the severity of other symptoms such as pain, dysphagia, and anxiety.

C. Esophageal cancer can cause significant pain due to tissue destruction by the tumor, which can affect the client's quality of life and ability to function. This however, should be addressed after immediate concerns in the ABCs.

D. While addressing the client's emotional needs is important for holistic care, it may not be the immediate priority compared to managing symptoms such as pain and dysphagia,

Correct Answer is D

Explanation

D. The priority nursing intervention should be to assess and stabilize the patient's immediate medical needs. The confusion and vomiting could be indicative of increased intracranial pressure or another acute condition requiring immediate attention. Therefore, the most appropriate first action would be to complete a head-to-toe neurological assessment.

A. Determining the last dose of corticosteroids may not address the immediate concerns of confusion and projectile vomiting.

B. Administering an antiemetic is not the priority action as the vomiting is likely due to head trauma with subsequent raised ICP.

C. Understanding the baseline neurological status is essential for subsequent assessment and management but it may not address the immediate concerns of confusion and vomiting.

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