Nokea
A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which is the earliest clinical manifestation of acute respiratory distress syndrome (ARDS) the nurse should monitor for?
- A. Cyanosis with accompanying pallor
- B. Diffuse crackles and rhonchi on chest auscultation
- C. Increase in respiratory rate from 18 to 30 breaths per minute
- D. Haziness or 'white-out' appearance of lungs on chest radiograph
Correct Answer: C
Rationale: ARDS usually develops within 24 to 48 hours after an initiating event, such as chest trauma. In most cases, tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventilation. Cyanosis and pallor are late findings and are the result of severe hypoxemia. Breath sounds in the early stages of ARDS are usually clear but then progress to diffuse crackles and rhonchi as pulmonary edema occurs. Chest radiographic findings may be normal during the early stages but will show diffuse haziness or 'white-out' appearance in the later stages.
You may also like to solve these questions
The nurse admits a client who is bleeding freely from a scalp laceration that resulted from a fall. The nurse should take which action first in the care of this wound?
- A. Prepare for suturing the area.
- B. Determine when the client last had a tetanus vaccine.
- C. Cleanse the wound by flushing with sterile normal saline.
- D. Apply direct pressure to the laceration to stop the bleeding.
Correct Answer: D
Rationale: In the presence of active bleeding from a scalp laceration, the priority is to control the bleeding to prevent further blood loss and stabilize the client. Applying direct pressure to the laceration is the most effective initial action to achieve this. Preparing for suturing, determining tetanus vaccine status, and cleansing the wound are important but secondary actions that follow after bleeding is controlled.
A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
- A. Peanut butter and jelly sandwich, apple, tea
- B. Chicken breast, broccoli, strawberries, milk
- C. Veal chop, boiled potatoes, Jell-O, orange juice
- D. Pasta with tomato sauce, garlic bread, ginger ale
Correct Answer: B
Rationale: The meal with the best potential to promote wound healing includes nutrient-rich food choices, including protein, such as chicken and milk, and vitamin C, such as broccoli and strawberries. The remaining options include one or more items with a low nutritional value, especially the tea, jelly, Jell-O, and ginger ale.
A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will have which characteristic?
- A. Malodorous
- B. Dark in color
- C. Unusually hard
- D. Abnormally small in amount
Correct Answer: A
Rationale: Celiac disease is a disorder characterized by intolerance to gluten, leading to malabsorption and gastrointestinal symptoms. The stools of a child with celiac disease are typically malodorous, bulky, frothy, and pale due to steatorrhea (excess fat in the stool) caused by impaired nutrient absorption. Dark-colored stools, hard stools, or small amounts are not characteristic of celiac disease.
A hospitalized client awaiting repair of an unruptured cerebral aneurysm is frequently assessed by the nurse. Which assessment finding should the nurse identify as an early indication that the aneurysm has ruptured?
- A. Widened pulse pressure
- B. Unilateral motor weakness
- C. Unilateral slowing of pupil response
- D. A decline in the level of consciousness
Correct Answer: D
Rationale: Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure in the brain is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain than those that control consciousness, blood pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.
An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats per minute, blood pressure (BP) 158/88 mm Hg, and respirations 28 breaths per minute. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes a pulse of 82 beats per minute, BP 130/80 mm Hg, and respirations 20 breaths per minute. Which factor likely accounts for the change in vital signs?
- A. Cooling effects of the cleansing agent
- B. Client's adaptation to the air conditioning
- C. Early clinical indicators of cardiogenic shock
- D. Decline in sympathetic nervous system discharge
Correct Answer: D
Rationale: Physical or emotional stress triggers sympathetic nervous system stimulation. Increased epinephrine and norepinephrine cause tachycardia, high blood pressure, and tachypnea. Stress reduction then returns these parameters to baseline as the sympathetic discharge falls.