A nurse is caring for a client who develops a sudden onset of dyspnea. Which of the following findings should the nurse expect if the client has a pulmonary embolus?
Expiratory rhonchi.
Petechiae over the lower extremities.
Hemoptysis.
Flattened neck veins.
The Correct Answer is C
Choice A rationale:
Expiratory rhonchi are typically associated with conditions such as chronic bronchitis or asthma but are not specific to pulmonary embolism.
Choice B rationale:
Petechiae over the lower extremities is not a characteristic finding in pulmonary embolism. Petechiae are tiny red or purple spots that appear due to bleeding under the skin and may be associated with other conditions like thrombocytopenia.
Choice C rationale:
The correct choice. Hemoptysis, which refers to coughing up blood, is a concerning finding in pulmonary embolism. It occurs due to the obstruction of blood flow in the pulmonary vasculature, leading to blood leaking into the lungs.
Choice D rationale:
Flattened neck veins are more likely to be observed in conditions associated with decreased venous return to the heart, such as hypovolemia or cardiac tamponade, and are not directly related to pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The nurse should not instruct the older adult client with osteoporosis to increase high-impact activities. Osteoporosis is a condition characterized by decreased bone density and strength, making high-impact activities potentially harmful as they could increase the risk of fractures.
Choice B rationale:
The nurse should not advise the client to consume a low-protein diet. Adequate protein intake is essential for maintaining muscle mass and overall musculoskeletal health, especially in older adults who may be at risk of muscle wasting.
Choice C rationale:
The nurse should not encourage the client to maintain a BMI of 30 to 35. A BMI within this range is considered obese and can put additional stress on the musculoskeletal system, increasing the risk of joint problems and other health issues.
Choice D rationale:
Including fiber in the diet is a correct instruction for promoting musculoskeletal health. Fiber-rich foods can help maintain bowel regularity and prevent constipation, which is important for overall comfort and mobility in older adults with osteoporosis.
Correct Answer is C
Explanation
Choice A rationale:
This statement indicates the client's fear and concern about the colostomy's odor, showing a lack of adaptation to the situation.
Choice B rationale:
Comparing the stoma to a strawberry with a hole in it might suggest the client is not fully accepting or understanding the colostomy, indicating a lack of adaptation.
Choice C rationale:
This statement suggests that the client has delegated the task of emptying the colostomy bag to their partner, which indicates a level of acceptance and adaptation to the new situation.
The client trusts their partner with this intimate task, demonstrating a positive sign of adaptation.
Choice D rationale:
Eliminating many foods from the diet suggests difficulty in adjusting to the dietary changes required for managing a colostomy, indicating a lack of full adaptation.
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