A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based?

Extra pillows can be used if needed to elevate the client's head.

The procedure is performed with the client in an upright position.

A thoracentesis is a brief procedure that has minimal discomfort.

Orthopnea is frequently caused by a client's uncontrolled anxiety.

Answer and Explanation

The Correct Answer is B

Choice A reason: Using extra pillows may help with comfort but is not the basis of the nurse's response to the concern about thoracentesis.

Choice B reason:

The correct answer is b) because during thoracentesis, the client is positioned upright, which helps ease breathing and access the pleural space.

Choice C reason: While the procedure may be brief, this response does not directly address the concern about breathing.

Choice D reason: Orthopnea can be caused by conditions other than anxiety and should be addressed appropriately.

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Correct Answer is C

Explanation

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

A. Hypotension and venous pooling in the extremities. B. Pain and a burning sensation upon urination and hematuria. C. Profuse diaphoresis and severe, pounding headache. D. Reports of chest pain and shortness of breath.

Correct Answer is C

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason:

The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

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A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based?

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