Why does the nurse instruct the client to avoid Valsalva maneuvers?

Correct Answer: C

Rationale: The nurse instructs the client to avoid Valsalva maneuvers because the client may suffer from a myocardial infarction. The Valsalva maneuver involves forcefully trying to exhale against a closed airway, which can increase intra-thoracic pressure and subsequently increase blood pressure. This can lead to an increased workload on the heart, potentially causing myocardial ischemia or infarction in individuals with underlying heart conditions. Therefore, it is important to avoid Valsalva maneuvers, especially in clients at risk for cardiovascular issues.

Correct Answer: A

Rationale: The medulla oblongata, located in the brainstem, is responsible for controlling essential autonomic functions such as breathing, heart rate, and blood pressure. Specifically, the medulla regulates the rhythm and depth of breathing by sending signals to the respiratory muscles, including the diaphragm and intercostal muscles. In response to changing levels of oxygen and carbon dioxide in the blood, the medulla adjusts the breathing rate to maintain proper oxygenation of the body tissues. Damage to the medulla can result in respiratory failure, highlighting its critical role in controlling breathing.

Correct Answer: C

Rationale: Elevating the head of the bed is an important intervention to help prevent complications in patients with impaired respiratory function. By elevating the head of the bed, gravity assists in improving lung expansion and ventilation, making breathing easier for the patient. This position promotes better airflow and can help reduce the risk of respiratory complications such as aspiration. It is a non-invasive and simple intervention that can be easily implemented in a home care setting to support the patient's respiratory function and overall well-being. Antibiotics, bedrest, and scheduled suctioning are not directly related to improving respiratory function in this context.

Correct Answer: D

Rationale: Inhalation of carbogen (a mixture of carbon dioxide and oxygen) for a short period is recommended for various reasons in pediatric patients. The correct answer, option D, "All of the above," is correct because carbogen can stimulate respiration, dilate blood vessels, and dislodge blood clots. Carbogen stimulates respiration by increasing the levels of oxygen in the body, which can help in situations where there is respiratory distress. It dilates blood vessels by increasing blood flow and oxygen delivery to tissues, which can be beneficial in conditions like vascular insufficiency. Carbogen can also help dislodge blood clots by improving blood flow and oxygenation, potentially preventing serious complications like stroke. Options A, B, and C are incorrect because they do not encompass the comprehensive effects of carbogen inhalation. While they touch on some individual benefits, the correct option, D, provides a holistic view of the advantages of using carbogen in pediatric patients. In an educational context, understanding the effects of carbogen inhalation is crucial for nursing students preparing for the NCLEX-RN exam. It reinforces the importance of knowing the pharmacological actions of common medications and treatments used in pediatric care, highlighting the multifaceted benefits of interventions like carbogen inhalation in clinical practice.

Correct Answer: D

Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.