A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.)
(Select All that Apply.)

Pleural cavity decompression via needle aspiration

Focused assessment with sonography in trauma (FAST)

Chest x-ray

Thoracentesis

Ultrasound

Answer and Explanation

Correct Answer : B,C,D,E

Choice A Reason:

Pleural cavity decompression via needle aspiration is inappropriate. Pleural cavity decompression via needle aspiration may be indicated in cases of tension pneumothorax, a potentially life-threatening condition in which air accumulates in the pleural space and compresses the lung. While it is an intervention rather than a diagnostic tool, it may be performed emergently if tension pneumothorax is suspected based on clinical findings.

Choice B Reason:

Focused assessment with sonography in trauma (FAST) is appropriate. FAST is a bedside ultrasound examination commonly used in trauma settings to rapidly assess for the presence of free fluid in the pericardial, pleural, and peritoneal spaces. It can help identify hemopericardium, hemothorax, or intra-abdominal hemorrhage, which may be indicative of thoracic injury.

Choice C Reason:

Chest x-ray is appropriate. Chest x-ray is a commonly used imaging modality for evaluating thoracic injuries. It can help visualize abnormalities such as rib fractures, pneumothorax, hemothorax, pulmonary contusions, or other traumatic injuries to the chest.

Choice D Reason:

Thoracentesis is appropriate. Thoracentesis is a procedure used to sample fluid from the pleural space for diagnostic or therapeutic purposes. It may be indicated if there is a suspicion of pleural effusion or if fluid accumulation is seen on imaging studies such as chest x-ray or ultrasound.

Choice E Reason:

Ultrasound is appropriate. Ultrasound can be used to evaluate various aspects of thoracic injuries, including the presence of pneumothorax, hemothorax, or pleural effusion. It is often used as part of the FAST examination but can also be performed separately for more detailed assessment.

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Correct Answer is A

Explanation

Choice A Reason:

The client should maintain systolic BP between 120 and 129 mm Hg. This option aligns with current guidelines for blood pressure management following a transient ischemic attack (TIA). Tight blood pressure control is recommended to reduce the risk of recurrent cerebrovascular events, such as stroke. Maintaining systolic blood pressure (SBP) between 120 and 129 mm Hg has been associated with significant risk reduction in stroke recurrence compared to higher blood pressure targets. Therefore, this option reflects the recommended approach for blood pressure management in individuals with a history of TIA.

Choice B Reason:

The client should maintain systolic BP between 136 and 140 mm Hg: This option suggests a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 136 to 140 mm Hg may pose an increased risk of recurrent cerebrovascular events compared to tighter blood pressure control.

Choice C Reason:

The client should maintain systolic BP between 141 and 145 mm Hg. Similarly, this option proposes a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 141 to 145 mm Hg may not provide adequate protection against stroke recurrence compared to tighter blood pressure control.

Choice D Reason:

The client should maintain systolic BP between 130 and 135 mm Hg. While this option suggests a systolic blood pressure (SBP) range that is closer to the recommended target compared to options B and C, it still falls slightly above the optimal range for blood pressure management following a TIA. Tighter blood pressure control, ideally below 130 mm Hg, is typically preferred to reduce the risk of recurrent cerebrovascular events.

A. Temperature 36.3° C (97.4° F) B. Respirations 12/min C. Blood pressure 184/88 mm Hg D. Heart rate 54/min E. Calcium level 7.0 mg/dL

Correct Answer is ["A","D"]

Explanation

Choice A Reason:

Temperature 36.3°C (97.4°F) is correct. Hypothermia is a characteristic finding in neurogenic shock due to the loss of sympathetic control over temperature regulation and peripheral vasodilation. This can lead to heat loss from the skin surface and a decrease in core body temperature.

Choice B Reason:

Respirations 12/min is incorrect. Respiratory rate is usually not significantly affected in neurogenic shock. However, individuals with high cervical or upper thoracic spinal cord injuries may experience respiratory compromise due to paralysis of respiratory muscles, but this is not a typical feature of neurogenic shock.

Choice C Reason:

Incorrect: Neurogenic shock typically results inhypotension(low blood pressure) due to vasodilation. The given blood pressure reading is elevated, which is not consistent with neurogenic shock.

Choice D Reason:

Heart rate 54/min is correct. Bradycardia is a common finding in neurogenic shock due to unopposed parasympathetic activity resulting from the loss of sympathetic tone. The heart rate may be slow and may decrease further over time.

Choice E Reason:

Calcium level 7.0 mg/dL is incorrect, Calcium levels are not directly related to neurogenic shock. Neurogenic shock primarily involves the loss of sympathetic tone and the resulting hemodynamic changes, rather than alterations in calcium metabolism.

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A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.) (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

Correct Answer is A

Explanation

A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Select all that apply.) (Select All that Apply.)

Correct Answer is ["A","D"]

Explanation

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A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.)
(Select All that Apply.)