A nurse is caring for a client who has flail chest. The nurse should identify the following information should the nurse include about adechest?

Coughing

Motor vehicle accidents

Falls

Assault

Answer and Explanation

The Correct Answer is B

A. Coughing: While coughing can be a symptom of respiratory distress or lung injury, it is not typically a direct cause of flail chest. Flail chest is characterized by multiple rib fractures leading to a segment of the chest wall moving independently, which can result from blunt trauma like a motor vehicle accident.
B. Motor vehicle accidents: Flail chest commonly results from significant trauma, such as that from a motor vehicle accident. The blunt force of the impact during an accident can cause multiple rib fractures, which can result in the characteristic paradoxical chest movement seen in flail chest.
C. Falls: Although falls can result in rib fractures, they are less likely to cause the severe trauma and multiple rib fractures required to result in flail chest. While serious falls could contribute to a flail chest in certain scenarios, motor vehicle accidents are more common for this type of injury.
D. Assault: While an assault can cause chest injuries, including rib fractures, it is less commonly associated with flail chest compared to the more significant force from motor vehicle accidents. The mechanism of injury in assaults may not involve the level of blunt trauma that leads to multiple rib fractures and flail chest.

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Correct Answer is ["A","C","E"]

Explanation

A. Swelling of the optic nerve: Swelling of the optic nerve, also known as papilledema, is a clear sign of increased intracranial pressure and indicates a worsening neurological condition. It results from pressure transmitted through the cerebrospinal fluid, leading to compromised optic nerve function.
B. Respiratory rate of 12/min: A respiratory rate of 12 breaths per minute is within normal limits for adults and does not indicate deterioration. While respiratory changes can be a late sign of increased ICP, a rate of 12 alone is not concerning.
C. Changes to pupil size and shape: Alterations in pupil size and shape often reflect pressure on cranial nerves, particularly the oculomotor nerve (CN III), which is a critical warning sign of brain herniation or increased ICP. This is a significant cue of neurologic decline.
D. Blood pressure of 108/74 mm Hg: This blood pressure reading is within a normal range and does not independently suggest a worsening neurologic condition. Worrisome signs would include widened pulse pressure or elevated systolic pressure, which may signal Cushing’s triad.
E. Decreasing Glasgow Coma scores: A drop in the Glasgow Coma Scale score indicates a decline in consciousness, which is a key sign of worsening intracranial pathology. Monitoring GCS trends is essential in patients with increased ICP to identify neurological deterioration early.

A. Client's age B. History of sickle cell disease C. Parent who has cardiovascular dis D. Hypertension

Correct Answer is D

Explanation

A. Client's age: Age is a non-modifiable risk factor for stroke. As individuals get older, their risk of stroke increases due to vascular changes, but this is not something that can be altered or controlled through interventions or lifestyle changes.
B. History of sickle cell disease: Sickle cell disease increases stroke risk due to its effects on blood viscosity and vessel occlusion, but it is a genetic condition. Therefore, it is considered a non-modifiable risk factor, although managing the disease can help reduce complications.
C. Parent who has cardiovascular disease: Having a parent with cardiovascular disease increases one’s risk for stroke due to inherited genetic predisposition. However, this familial risk is not something the client can change, making it a non-modifiable factor.
D. Hypertension: Hypertension is the most significant modifiable risk factor for stroke. It can be managed through lifestyle changes, medication, and monitoring, thereby significantly reducing the client’s risk of future strokes.

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A nurse is caring for a client who has flail chest. The nurse should identify the following information should the nurse include about adechest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is reviewing the electronic medical record of a middle-aged client who was admitted following a stroke. Which of the following findings should the nurse identify as a modifiable risk factor for stroke?

Correct Answer is D

Explanation

A nurse is caring for a client who has flail chest. The nurse should identify the following information should the nurse include about adechest?

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