A nurse is caring for a client involved in a motor vehicle accident 4 hours ago and states, "I just can't breathe.”. The nurse assesses that the client is restless, tachycardic, and has an elevated blood pressure.
The nurse should anticipate that the client may be experiencing which condition?

Pleural effusion.

Acute respiratory failure.

Closed head trauma.

Traumatic brain injury.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Pleural effusion, the accumulation of fluid in the pleural space, typically causes dyspnea and diminished breath sounds over the affected area. While it can cause respiratory distress, the specific symptoms of restlessness, tachycardia, and elevated blood pressure, especially in the context of an acute event like a motor vehicle accident, point more broadly to overall respiratory compromise.

Choice B rationale

Acute respiratory failure is characterized by the inability of the respiratory system to maintain adequate gas exchange, leading to hypoxemia and/or hypercapnia. The client's symptoms of restlessness (due to hypoxemia), tachycardia (compensatory mechanism), and elevated blood pressure (sympathetic response to stress and hypoxemia) are classic signs of impending or actual respiratory failure following trauma.

Choice C rationale

Closed head trauma, an injury to the brain without penetration of the skull, can certainly impact respiratory drive if severe. However, the immediate and primary manifestation of "I just can't breathe" with associated physiological signs like restlessness, tachycardia, and elevated blood pressure directly indicates a compromise in oxygenation and ventilation, which aligns more with respiratory failure.

Choice D rationale

Traumatic brain injury (TBI) encompasses a range of injuries to the brain. While TBI can lead to respiratory compromise, the client's direct statement "I just can't breathe" along with the described physiological responses (restlessness, tachycardia, elevated blood pressure) are more indicative of the immediate consequences of impaired gas exchange stemming from acute respiratory distress, which is a symptom of underlying trauma.

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Correct Answer is B

Explanation

Choice A rationale

Managing emotions is an important aspect of conflict resolution, but it typically occurs after the problem has been clearly identified and understood. Emotional responses can hinder effective communication if the core issues are not yet established.

Choice B rationale

Clarifying the problem involves gathering information, understanding different perspectives, and identifying the underlying issues contributing to the conflict. This step is foundational in negotiation, as it ensures all parties agree on what needs to be resolved before seeking solutions.

Choice C rationale

Breaking the ground rules would be counterproductive to a negotiation process, as established rules provide structure and fairness. Adhering to agreed-upon guidelines is crucial for a constructive and respectful discussion aimed at resolution.

Choice D rationale

Disregarding the conflict would escalate tensions and prevent resolution. Effective conflict management requires direct engagement with the issues and a commitment to finding mutually acceptable solutions rather than avoidance.

A. Carrots, green leafy vegetables, a pear. B. Cold cuts with bun, blueberries. C. Spaghetti with meat sauce, breadstick. D. Hamburger on a bun, banana.

Correct Answer is A

Explanation

Choice A rationale

Carrots, green leafy vegetables, and a pear are generally good choices for chronic renal disease. Carrots are relatively low in potassium, green leafy vegetables, while some are high in potassium, can be managed with portion control and specific preparation methods, and pears are low in potassium and phosphorus. This selection demonstrates an understanding of limiting electrolytes.

Choice B rationale

Cold cuts are typically high in sodium and phosphorus due to processing and preservatives, which are detrimental for clients with chronic renal disease. Blueberries are a good choice as they are low in potassium and phosphorus, but the cold cuts make this choice unsuitable due to their high sodium and phosphorus content.

Choice C rationale

Spaghetti with meat sauce often contains high levels of phosphorus and sodium. Meat can be high in phosphorus, and sauces may contain added sodium. Breadsticks can also contribute significant sodium. These components exceed the recommended dietary restrictions for renal disease patients.

Choice D rationale

A hamburger on a bun can be high in phosphorus and sodium, especially if processed. Bananas are notoriously high in potassium, a critical electrolyte that clients with chronic renal disease often need to restrict to prevent hyperkalemia due to impaired renal excretion. This choice is therefore inappropriate.

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A nurse is caring for a client involved in a motor vehicle accident 4 hours ago and states, "I just can't breathe.”. The nurse assesses that the client is restless, tachycardic, and has an elevated blood pressure. The nurse should anticipate that the client may be experiencing which condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

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A nurse is caring for a client involved in a motor vehicle accident 4 hours ago and states, "I just can't breathe.”. The nurse assesses that the client is restless, tachycardic, and has an elevated blood pressure.
The nurse should anticipate that the client may be experiencing which condition?