A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?
"I am concerned about my child's future participation in team sports."
"My child doesn't like to sit still for nebulizer treatments."
"My child has only a small amount of mucus after percussion therapy."
"I think that my child has been running a fever over the last couple of days."
The Correct Answer is C
Rationale:
A. Concerns about participation in team sports are important, but they do not directly warrant a request for a high-frequency chest compression vest.
B. Discomfort with nebulizer treatments suggests the need for alternate therapies but does not specifically indicate a need for the vest.
C. A statement regarding a small amount of mucus after percussion therapy suggests that traditional methods of airway clearance may not be effective enough, indicating a need for a high-frequency chest compression vest to help mobilize mucus.
D. A fever may indicate an infection or exacerbation but does not directly relate to the need for a high-frequency chest compression vest.
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Correct Answer is C
Explanation
Rationale:
A. Compensated metabolic acidosis would show a normal pH with a decrease in HCO3- and a decrease in PaCO2.
B. Compensated respiratory acidosis would show a normal pH with an elevated PaCO2 and a compensatory increase in HCO3-.
C. The low pH indicates acidosis, and the elevated PaCO2 suggests that it is respiratory in origin, with the HCO3- remaining normal, indicating no compensation has occurred yet.
D. Uncompensated metabolic acidosis would present with a low pH, low HCO3-, and normal PaCO2.
Correct Answer is C
Explanation
Rationale:
A. Reporting suspected child maltreatment is a legal and ethical responsibility of the nurse; this action is appropriate and does not require intervention.
B. Notifying the health department about a client's diagnosis of chlamydia is a legal requirement, as it is a reportable disease, so this action is appropriate.
C. Sharing a client’s diagnosis with a hospital chaplain without the client's consent could violate the client's confidentiality and requires intervention.
D. Informing the provider about a client's suicide plan is a critical action for patient safety and does not require intervention.