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A nurse in the emergency department is caring for a patient who was injured in a motor-vehicle crash. The patient reports dyspnea and severe pain. The nurse notes that the patient's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? What condition is indicated by paradoxical chest movement?
- A. Flail chest
- B. Hemothorax
- C. Atelectasis
- D. Pneumothorax
Correct Answer: A
Rationale: The correct answer is A: Flail chest. Flail chest is characterized by a segment of the rib cage that moves independently due to multiple rib fractures. The paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration, is a classic sign of flail chest. This occurs due to the loss of stability in the rib cage, leading to ineffective breathing mechanics.
Incorrect answers:
B: Hemothorax - This is the accumulation of blood in the pleural cavity, which would not cause paradoxical chest movement.
C: Atelectasis - Atelectasis is the collapse of lung tissue, which would not result in paradoxical chest movement.
D: Pneumothorax - Pneumothorax is the presence of air in the pleural space, which typically causes chest pain and shortness of breath but does not result in paradoxical chest movement.
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A nurse is caring for a toddler. The nurse's observations are as follows: Heart rate: 150/min, Temperature: 38.9°C (102°F), Respiratory rate: 28/min, Oxygen saturation: 96% on room air, Blood Pressure: 90/43 mm Hg. What should the nurse do next? What should the nurse do next for toddler vital signs?
- A. Monitor the toddler's vital signs closely.
- B. Administer supplemental oxygen.
- C. Notify the healthcare provider.
- D. Reassess the toddler in 15 minutes.
Correct Answer: A
Rationale: Rationale: Option A is correct as the toddler's vital signs are within acceptable ranges. The heart rate, respiratory rate, and oxygen saturation are normal for a toddler. The elevated temperature may indicate a fever, but it is not alarming. The blood pressure is slightly low but still acceptable. Therefore, the nurse should monitor the toddler's vital signs closely to assess for any changes. Administering oxygen, notifying the healthcare provider, or reassessing in 15 minutes are not necessary at this point as the vital signs do not indicate immediate concern. Monitoring closely allows for timely detection of any deterioration or improvement in the toddler's condition.
A nurse is providing health promotion education to the parents of a toddler. Which information should the nurse include in the teaching?,Which information should be included in toddler health promotion education?
- A. Need for increased caloric intake.
- B. How to establish trust.
- C. Management of tantrums.
- D. How to encourage cooperative play.
- E. Dental care.
Correct Answer: A,C,D,E
Rationale: The correct answer includes information on caloric intake (A) to ensure the toddler's proper growth and development. Management of tantrums (C) is crucial for behavioral management. Encouraging cooperative play (D) fosters social skills. Dental care (E) is essential for oral health. Establishing trust (B) is important but not directly related to health promotion. No information is given for choices F and G.
A nurse is educating a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a potential treatment for brain herniation? Which intervention is a potential treatment for brain herniation?
- A. Hyperventilate the patient.
- B. Decrease sedation.
- C. Reduce the temperature in the room.
- D. Lower blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Hyperventilate the patient. Hyperventilation helps to decrease the PaCO2 levels, leading to vasoconstriction and decreased cerebral blood flow, which can help reduce intracranial pressure associated with brain herniation. This intervention aims to improve cerebral perfusion and prevent further brain damage. Decreasing sedation (choice B) may be necessary to assess the patient's neurological status, but it does not directly address brain herniation. Reducing the room temperature (choice C) can help in managing fever, but it does not target brain herniation. Lowering blood pressure (choice D) may be necessary in some cases, but it is not a primary treatment for brain herniation.
A nurse is instructing a patient who has just been prescribed bumetanide. What should the nurse include in the instructions? What should the nurse include in bumetanide instructions?
- A. Take the prescribed second dose at nighttime.
- B. Limit your fluid intake to no more than 1.5 L a day.
- C. Report any changes in hearing.
- D. Avoid foods high in potassium.
Correct Answer: C
Rationale: The correct answer is C: Report any changes in hearing. Bumetanide is a loop diuretic that can cause ototoxicity, leading to changes in hearing. Instructing the patient to report any changes in hearing is crucial to monitor for potential adverse effects. Choice A is incorrect as bumetanide is usually taken once daily in the morning to prevent nocturia. Choice B is incorrect as the patient may need to increase fluid intake to prevent dehydration. Choice D is incorrect as bumetanide can lead to hypokalemia, so foods high in potassium may be beneficial.
A nurse is caring for a patient hospitalized for the treatment of severe depression. Which of the following nursing approaches should be included in the patient's care plan? Which approach should be included for severe depression?
- A. Spend time sitting with the patient.
- B. Offer the patient choices of activities.
- C. Establish a patient relationship.
- D. Explore the truth of the patient's statements.
Correct Answer: A
Rationale: The correct answer is A: Spend time sitting with the patient. Spending time with the patient demonstrates empathy, support, and a willingness to listen, which are crucial for patients with severe depression. It helps build a therapeutic relationship and provides emotional comfort. Choice B focuses more on autonomy and may not address the patient's emotional needs. Choice C is important but is a broad concept that is encompassed by spending time with the patient. Choice D may come off as confrontational and potentially exacerbate the patient's distress.