Nokea
A client is admitted to the emergency department after sustaining multiple rib fractures in a motor vehicle accident. Upon assessment, the nurse notes that the client has flail chest. Which of the following signs and symptoms are associated with this condition? (Select all that apply.)
- A. Bradycardia
- B. Anxiety
- C. Dyspnea
- D. Unequal chest expansion
- E. Hypotension
- F. Paradoxical chest movement
Correct Answer: B,C,D,E,F
Rationale: Flail chest causes respiratory distress, paradoxical movement, and can lead to shock.
You may also like to solve these questions
A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).
- A. Tachycardia
- B. Rebound tenderness
- C. Rigid abdomen
- D. Elevated blood pressure
Correct Answer: A,B,C
Rationale: These are classic signs of perforation and peritonitis: tachycardia from pain/stress, rebound tenderness and rigidity from peritoneal irritation.
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). Which of the following medications should the nurse plan to administer after the initial acute phase to manage the client's pain and anxiety?
- A. Nitroglycerin
- B. Aspirin
- C. Oxygen
- D. Morphine
Correct Answer: D
Rationale: Morphine is used for pain/anxiety management post-MI after acute interventions.
The healthcare provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?
- A. I was an intravenous drug abuser in the past and shared needles.
- B. I ate shellfish about 2 weeks ago at a local restaurant.
- C. I had a blood transfusion 30 years ago after major abdominal surgery.
- D. I have had unprotected sex with multiple partners.
Correct Answer: B
Rationale: Hepatitis A is typically transmitted through contaminated food/water - shellfish is a known source.
A client is admitted to the hospital with suspected rheumatic endocarditis. Which of the following laboratory tests would assist in confirming the diagnosis?
- A. Liver enzymes
- B. Serum albumin
- C. Throat culture
- D. Arterial blood gases
Correct Answer: C
Rationale: Throat culture can identify streptococcal infection preceding rheumatic fever/endocarditis.
The nurse is assessing for asterixis in a client with cirrhosis. How should the nurse assess for asterixis?
- A. Instruct the client to lean forward.
- B. Ask the client to extend the arms.
- C. Dorsiflex the client's foot.
- D. Measure the abdominal girth.
Correct Answer: B
Rationale: Asterixis (liver flap) is assessed by having patient extend arms and observing for involuntary flapping motions.