Share This Link

Rising water levels during inspiration and falling during expiration are indicative of proper chest tube function, therefore, auscultation for breath sounds may not provide additional relevant information related to the functioning of the chest tube.

Performing this action unnecessarily may disrupt the functioning of the drainage system and should only be done if specifically instructed by the healthcare provider.

While it is important to monitor for leaks, the observation of tidaling in the water-seal chamber does not necessarily indicate a leak at the insertion site.

Forehead diaphoresis, or sweating, is a potential symptom of autonomic dysreflexia. However, it is more of a consequence rather than a precipitating factor. It occurs as a result of sympathetic nervous system activation in response to the triggering stimulus.

Skeletal traction misalignment is not a common precipitating factor for autonomic dysreflexia. Autonomic dysreflexia is typically triggered by stimuli related to visceral or autonomic reflexes, such as bladder distention or bowel impaction, rather than mechanical issues like traction misalignment.

A severe pounding headache can occur as a symptom of autonomic dysreflexia, but it is not the primary precipitating factor. The headache is a result of the sudden increase in blood pressure that occurs during autonomic dysreflexia.

Hemoccult tests are used to detect hidden (occult) blood in stool samples. While hemoptysis (coughing up blood) can be a symptom of TB, a hemoccult test is not specific for TB diagnosis. It is more commonly used in detecting gastrointestinal bleeding.

Imaging studies like chest x-ray or CT scans can reveal abnormalities in the lungs suggestive of TB, such as infiltrates, cavitations, or lymph node enlargement. While these tests can support the diagnosis, they are not definitive on their own.

The PPD skin test is a common screening tool for TB exposure. It detects the presence of a delayed hypersensitivity reaction to proteins derived from Mycobacterium tuberculosis. A positive PPD indicates exposure to TB but does not confirm active disease.

Lactulose is required in clients with hepatic encephalopathy to excrete ammonia lowering its levels in blood. Holding the lactulose dose is inappropriate as the client’s ammonia levels are still high

Rehydrating the clients to replace lost fluids in the loose stools is important but does not addressthe client’s elevated ammonia levels which may be exacerbating the client’s encephalopathy.

Reporting the number of diarrhea stools to the healthcare provider is important for ongoing assessment and management of the client's condition. However, it does not address the clients high ammonia levels.

describes symptoms more suggestive of irritable bowel syndrome (IBS) or gastrointestinal sensitivity to spicy foods, leading to cramps and diarrhea, but it is less specific to PUD.

indicates frequent use of antacids for indigestion, which may suggest symptoms of acid reflux or gastritis but do not specifically point to the presence of peptic ulcers.

suggests more severe systemic issues such as malignancy or chronic diseases rather than solely PUD.

Complete restriction of physical activities is not necessary. The nurse should provide guidance on gradually resuming normal activities based on the healthcare provider's recommendations.

Incentive spirometer is not directly related to the management or recovery following TUNA for BPH. This device is typically used to improve lung function and prevent respiratory complications, which may not be a primary concern in this scenario.

While monitoring urinary output is important, a decrease in urinary stream output may not be the most relevant parameter to monitor specifically after a TUNA procedure. Instead, the focus should be on assessing for signs of bleeding, infection, or urinary retention.

While activity intolerance is a common nursing diagnosis for clients following an acute myocardial infarction due to myocardial ischemia, it is not the priority in this case where the client is actively receiving thrombolytic therapy.

While respiratory complications can occur following thrombolytic therapy, such as pulmonary embolism or bleeding into the lungs, the risk of bleeding complications takes precedence as the priority nursing problem for this client.

Education about the new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period.

While a slightly elevated heart rate may be expected in the immediate postoperative period due to stress or pain, it does not typically require immediate action unless accompanied by other concerning symptoms.

Redness and edema at the incision site can be normal inflammatory responses following surgery.

Pain is common after surgery, and a pain rating of 8 on a scale of 0 to 10 indicates moderate to severe pain.

Lower extremity is a typical finding in right ventricular dysfunction. Inadequate pumping in the right ventricular leads to volume overload in the systemic circulation.

Hepatomegaly is a typical finding in right ventricular dysfunction

Jugular vein dysfunction is a typical finding in right ventricular dysfunction.