A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of apneumothorax?
Inspiratory stridor
Expiratory wheeze
Coarse crackles
Absence of breath sounds.
The Correct Answer is D
A. Inspiratory stridor - This is associated with upper airway obstruction and is not indicative of a pneumothorax.
B. Expiratory wheeze - Wheezing is commonly associated with lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD), not pneumothorax.
C. Coarse crackles - Coarse crackles are typically heard in conditions such as pneumonia or pulmonary edema, not pneumothorax.
D. Absence of breath sounds - This is a key manifestation of a pneumothorax. The air in the pleural space can prevent the lung from fully expanding, leading to the absence of breath sounds on the affected side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Battle's sign: Battle's sign is bruising over the mastoid process and is not a direct manifestation of increased intracranial pressure.
b. Nuchal rigidity: Nuchal rigidity (stiff neck) is associated with irritation of the meninges and is not a specific sign of increased intracranial pressure.
c. Lethargy: Lethargy or altered level of consciousness is a common manifestation of increased intracranial pressure. It can range from mild drowsiness to severe impairment of consciousness.
d. Polyuria: Polyuria is not a typical manifestation of increased intracranial pressure. Increased urine output may be associated with other conditions, such as diabetes or diuretic use.
Correct Answer is D
Explanation
a. Eating dinner early in the evening: Eating dinner early can actually be a positive factor in preventing heartburn by allowing more time for digestion before lying down.
b. Sleeping on a large wedge-style pillow: Elevating the upper body can help prevent acid reflux, so sleeping on a wedge-style pillow may be a helpful strategy.
c. Consuming low-fat meats: Low-fat meats are less likely to contribute to heartburn compared to high-fat meats.
d. Drinking orange juice regularly: Orange juice is acidic and can contribute to heartburn,
especially if consumed regularly. The acid content can irritate the esophagus and worsen GERD symptoms.
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