A nurse is assessing a client who has flail chest. Which of the following findings should the nurse expect?
Only the flail segment pulling inward during expiration
The entire chest pulling inward during expiration
The entire chest pushing outward during inspiration
Only the flail segment pulling inward during inspiration
The Correct Answer is D
A. Only the flail segment pulling inward during expiration: During expiration, the pressure inside the chest decreases, and typically the chest wall recoils outward. A flail segment moves abnormally in the opposite direction during inspiration, not expiration.
B. The entire chest pulling inward during expiration: Inward movement of the entire chest during expiration is not characteristic of flail chest. This could suggest severe respiratory distress or chest wall weakness, but not the hallmark sign of flail chest.
C. The entire chest pushing outward during inspiration: This is a normal movement during inspiration and not specific to flail chest. In flail chest, the abnormality is seen in the flail segment, not the entire chest.
D. Only the flail segment pulling inward during inspiration: This is the classic finding in flail chest. Due to the broken ribs losing continuity with the rest of the rib cage, the flail segment moves paradoxically—inward during inspiration and outward during expiration—opposite to the normal chest wall motion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lower oxygen saturations of 93% to 94%: Older adults with pneumothorax may present with lower oxygen saturations as the collapsed lung leads to impaired gas exchange. Oxygen saturation levels of 93% to 94% may indicate mild hypoxemia in these clients.
B. Lower energy expenditure: Pneumothorax in older adults is more likely to result in respiratory symptoms like hypoxemia, rather than directly affecting energy expenditure.
C. Higher oxygen saturations of 98% to 99%: This is unlikely in the presence of pneumothorax, which typically causes hypoxemia due to impaired lung function. High oxygen saturation levels would not be expected.
D. Increased lung capacity: Pneumothorax causes lung collapse, which results in decreased lung capacity and is not associated with increased lung function.
Correct Answer is A
Explanation
A. Crohn's disease has the appearance of a patchwork quilt with some areas that are clear and some with sores: This description simplifies the concept of Crohn's disease by using the analogy of a patchwork quilt, which helps convey the characteristic "skip lesions" seen in the condition. In Crohn's disease, areas of inflammation (sores) are interspersed with healthy tissue, making this analogy easily understandable for a client without medical knowledge.
B. Crohn's disease looks like what would appear to be a second-degree burn in the colon and rectum areas only: This description falsely limits Crohn's disease to only the colon and rectum. Crohn's disease can affect any part of the gastrointestinal tract, from the mouth to the anus, and not just the colon or rectum. Additionally, comparing it to a burn may confuse the client, as it does not accurately depict the disease's pathophysiology.
C. Crohn's disease is characterized by a transmural granulomatous inflammation that can affect any part of the gastrointestinal tract: While this statement is medically accurate, it is complex and uses terminology (transmural, granulomatous) that may be difficult for a layperson to understand. For client education, it is better to use simpler language that avoids jargon and focuses on the general concept of the disease.
D. Crohn's disease causes continuous inflammation of the mucosa and sub-mucosa of the colon and rectal linings: This statement describes ulcerative colitis, not Crohn's disease. While Crohn's disease involves inflammation, it is characterized by patchy, non-continuous lesions (skip lesions), which differ from the continuous inflammation seen in ulcerative colitis.
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