A 76-year-old patient is 2 days post-op total hip replacement. The patient puts his call light on to complain of difficulty catching his breath. As the nurse assesses the patient, she finds the patient tachypneic, tachycardic, and very anxious. The nurse determines these are most likely signs of:

Pulmonary embolism

Left-sided heart failure

Early onset dementia

Acute myocardial infarction

Answer and Explanation

The Correct Answer is A

Choice A reason: Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. The signs and symptoms include sudden shortness of breath, rapid breathing (tachypnea), rapid heart rate (tachycardia), and anxiety. These symptoms align with the patient's presentation and are common in the post-operative period, particularly after orthopedic surgery, which increases the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism.

Choice B reason: Left-sided heart failure can cause symptoms such as shortness of breath, fatigue, and fluid retention. However, the acute presentation of difficulty breathing, tachypnea, tachycardia, and anxiety in the context of recent surgery is more suggestive of a pulmonary embolism. Heart failure symptoms generally develop gradually rather than suddenly.

Choice C reason: Early onset dementia is not characterized by acute respiratory symptoms like difficulty breathing, tachypnea, or tachycardia. Dementia symptoms typically include memory loss, confusion, and changes in cognitive function, not the acute cardiorespiratory symptoms described in this scenario.

Choice D reason: Acute myocardial infarction (heart attack) can cause shortness of breath, chest pain, and rapid heart rate. While it is a possibility, the combination of recent surgery and the described symptoms more strongly suggests a pulmonary embolism. An acute myocardial infarction would typically also present with chest pain, which is not mentioned in this scenario.

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Correct Answer is D

Explanation

Choice A reason: An epidural hematoma is a type of traumatic brain injury where blood accumulates between the dura mater and the skull. While it can cause severe symptoms, including headache, loss of consciousness, and neurological deficits, it does not typically present with ecchymosis behind the ears (Battle's sign) or bleeding from the ears. These signs are more indicative of a basilar skull fracture.

Choice B reason: An ischemic stroke occurs when a blood clot blocks or narrows an artery leading to the brain, causing reduced blood flow and oxygen to the brain tissue. Symptoms of an ischemic stroke include sudden weakness, numbness, difficulty speaking, and vision problems. However, it does not cause ecchymosis behind the ears or bleeding from the ears, which are specific signs of a basilar skull fracture.

Choice C reason: A subarachnoid hemorrhage is bleeding into the space between the brain and the tissue covering the brain (subarachnoid space). It often presents with a sudden, severe headache, nausea, vomiting, and loss of consciousness. While it is a serious condition, it does not typically cause ecchymosis behind the ears or bleeding from the ears.

Choice D reason: A basilar skull fracture is

The correct answer. This type of fracture involves the base of the skull and can cause characteristic signs such as ecchymosis behind the ears (Battle's sign) and bleeding from the ears due to the proximity of the fracture to the auditory canal and other structures. These symptoms are key indicators of a basilar skull fracture and require immediate medical attention.

A. Woman with a blood pressure of 158/90 mm Hg. B. Patient with Kussmaul respirations. C. Man with skin itching from head to toe. D. Patient with halitosis and stomatitis.

Correct Answer is B

Explanation

Choice A reason: A blood pressure of 158/90 mm Hg in a patient with chronic kidney disease (CKD) is elevated and requires management to prevent complications. However, it is not as immediately life-threatening as Kussmaul respirations, which indicate severe metabolic acidosis.

Choice B reason: The patient with Kussmaul respirations should be assessed first. Kussmaul respirations are deep, labored breathing patterns typically associated with severe metabolic acidosis, such as diabetic ketoacidosis (DKA) or severe kidney failure. This condition requires immediate intervention to correct the underlying acidosis and stabilize the patient's condition.

Choice C reason: Itching (pruritus) is a common symptom in CKD due to the accumulation of uremic toxins. While it can be very uncomfortable and requires treatment, it is not as urgent as Kussmaul respirations, which indicate a potentially life-threatening situation.

Choice D reason: Halitosis (bad breath) and stomatitis (inflammation of the mouth) can occur in CKD due to the buildup of uremic toxins and other factors. These symptoms need attention, but they do not indicate an immediate threat to the patient's life compared to Kussmaul respirations.

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A 76-year-old patient is 2 days post-op total hip replacement. The patient puts his call light on to complain of difficulty catching his breath. As the nurse assesses the patient, she finds the patient tachypneic, tachycardic, and very anxious. The nurse determines these are most likely signs of:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What condition does the nurse suspect when a patient involved in a motor vehicle accident arrives at the emergency department with ecchymosis behind the ears and bleeding from the ears?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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The 75-year-old client is hospitalized with end-stage chronic kidney disease. Which of the following serum lab findings would the nurse expect? Select all that apply.

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