A nurse is caring for a client newly diagnosed with a pulmonary embolism (PE). Which of the following is the initial assessment finding in the client diagnosed with PE?
Dyspnea and anxiety.
Altered level of consciousness.
Wheezing in lung bases.
Increased pulse and respiratory rate.
The Correct Answer is A
Choice A rationale
The initial assessment finding in a client diagnosed with a pulmonary embolism (PE) is typically dyspnea and anxiety. This is because a PE can block blood flow in the lungs, leading to difficulty breathing (dyspnea). The sudden onset of this symptom can cause significant anxiety in the patient.
Choice B rationale
An altered level of consciousness is not typically an initial finding in PE. While severe cases can lead to decreased oxygen levels in the blood, causing confusion or loss of consciousness, these are not usually initial symptoms.
Choice C rationale
Wheezing in lung bases is not a typical initial finding in PE. Wheezing is more commonly associated with conditions that cause narrowing of the airways, such as asthma or COPD12.
Choice D rationale
While an increased pulse and respiratory rate can occur in PE due to the body’s attempt to compensate for decreased oxygen in the blood, they are not the most specific initial findings. Dyspnea and anxiety are more characteristic initial symptoms of PE12.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Viral pharyngitis can sometimes lead to serious complications such as peritonsillar abscess. Symptoms of this condition include drooling and inability to fully open the mouth. Therefore, patients should be advised to contact a healthcare provider immediately if they experience these symptoms.
Choice B rationale
Viral pharyngitis is contagious and can be spread through saliva. Therefore, patients should be advised to avoid sharing drinks or eating utensils with others to prevent the spread of the infection.
Choice C rationale
Antibiotics are not effective against viral infections, including viral pharyngitis. Therefore, taking prescribed antibiotics on time and not missing doses is not relevant in the context of viral pharyngitis.
Choice D rationale
Checking the body for skin rash twice daily is not typically necessary for patients with viral pharyngitis. While some viruses can cause a rash, it is not a common symptom of viral pharyngitis.
Choice E rationale
Drinking at least 2-3 liters of fluid per day unless contraindicated can help soothe a sore throat and prevent dehydration, which can occur if the patient has a fever or is not eating well due to the sore throat.
Correct Answer is B
Explanation
Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
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