Nokea
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest?
- A. Respiratory acidosis
- B. Paradoxical chest movement
- C. Chest pain on inspiration
- D. Clubbing of fingers and toes
Correct Answer: B
Rationale: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.
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The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
- A. Pain in the feet
- B. Coolness to lower extremities
- C. Decreased urinary output
- D. LocalizedFixed calf tenderness
Correct Answer: D
Rationale: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.
The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and would assist in the diagnosis of an occupational lung disease?
- A. Cough and dyspnea
- B. Black-streaked sputum
- C. Tenacious secretions
- D. Barrel chest
Correct Answer: B
Rationale: A functional assessment provides data on the lifestyle, living environment, and work environment of the client, which can contribute to lung disorders. A black-tinged sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious secretions are vague respiratory symptoms that are not specific to occupational lung disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a prolonged period of time.
Which entry by the nurse into the medical record is appropriate for a client who presents with symptoms indicative of acute bronchitis?
- A. Physical activity seems to increase incidence of paroxysmal coughing
- B. Frequent cough with sputum production noted
- C. Dry, irritating, nonproductive cough noted
- D. Fewer crackles today. No cough or mucus noted
Correct Answer: C
Rationale: Clinical manifestations indicative of acute bronchitis include fever, chills, malaise, headache, and a dry, irritating, nonproductive cough; therefore, the entry made into the client's medical record that is indicative of this respiratory disorder is as follows: Dry, irritating, nonproductive cough noted. 'Physical activity seems to increase incidence of paroxysmal coughing' is a judgment and not an observation. A frequent cough with sputum production is not anticipated for a client who is suspected of experiencing acute bronchitis; additionally, there is no description of the client's sputum, which is required when documenting objective client data. Documenting fewer crackles today does not provide enough detail and is not measurable.
Following a hip repair, the client develops hemoptysis, wheezing, and cyanosis. The nurse suspects a pulmonary embolus that originated from which site?
- A. Deep veins of the legs
- B. Bone marrow
- C. Myocardial tissue
- D. Superior vena cava
Correct Answer: B
Rationale: A fat embolus usually occurs after a fracture or repair to the long bones. Pulmonary emboli may arise from the endocardium of the right side of the heart, but a myocardial infarction has not been identified in this client. The deep veins of the legs are a common site for emboli formation especially with prolonged inactivity or thrombophlebitis, which does not apply to this client.
In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk occupation(s)? Select all that apply.
- A. Banker
- B. Rock quarry worker
- C. Nurse
- D. Miner
- E. Mechanic
- F. Stone cutter
Correct Answer: B,D,F
Rationale: A quarry worker and stone cutter are exposed to rock dust and silica. A miner can inhale dust, causing silicosis or pneumoconiosis. A banker, nurse, and mechanic may have work hazards, but none specific to the development of an occupational lung disease.