A nurse is reinforcing teaching for a client who presents with a pulmonary embolism. Which of the following information should the nurse provide?
Treatment is not needed if the client is asymptomatic.
Treatment is not needed if the pulmonary embolism is intermediate.
Treatment is not needed if the client is hemodynamically stable.
Treatment is needed for all clients who have a pulmonary embolism.
The Correct Answer is D
A. Treatment is not needed if the client is asymptomatic.
Even asymptomatic pulmonary embolisms can lead to complications such as progression to symptomatic PE or development of chronic thromboembolic pulmonary hypertension. Therefore, treatment is necessary to prevent these complications.
B. Treatment is not needed if the pulmonary embolism is intermediate.
The severity of a pulmonary embolism is determined by various factors, including the size and location of the clot and the degree of obstruction in the pulmonary arteries. Intermediate-risk pulmonary embolisms still require treatment to prevent complications and reduce the risk of progression to a more severe or life-threatening condition.
C. Treatment is not needed if the client is hemodynamically stable.
Hemodynamic stability refers to the client's circulatory status and whether they are maintaining adequate blood flow to vital organs. While hemodynamically stable clients may not require aggressive interventions such as thrombolytic therapy or surgical embolectomy, they still require anticoagulant therapy to prevent further clot formation and reduce the risk of complications.
D. Treatment is needed for all clients who have a pulmonary embolism.
Pulmonary embolism (PE) is a serious and potentially life-threatening condition that requires prompt treatment. Regardless of the severity of symptoms or the client's hemodynamic stability, treatment is necessary to prevent complications and reduce the risk of recurrence. Treatment typically includes anticoagulant therapy to prevent further clot formation and may include additional interventions such as thrombolytic therapy or surgical interventions in certain cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pigeon
A pigeon chest, also known as pectus carinatum, is a deformity of the chest characterized by a protrusion of the sternum and ribs, resulting in a pigeon-like appearance of the chest. This deformity is not typically associated with COPD.
B. Funnel
A funnel chest, also known as pectus excavatum, is a deformity of the chest characterized by a depression or concavity in the sternum, resulting in a funnel-like appearance of the chest. This deformity is not typically associated with COPD.
C. Kyphotic
Kyphosis refers to an exaggerated forward curvature of the thoracic spine, leading to a hunched or rounded upper back. While individuals with severe COPD may develop kyphosis due to chronic respiratory muscle fatigue and increased work of breathing, kyphotic curvature is not specific to COPD and can occur in other conditions as well.
D. Barrel
In COPD (Chronic Obstructive Pulmonary Disease), the client's chest may take on a barrel shape. This is characterized by an increase in the anterior-posterior diameter of the chest, resulting in a more rounded appearance similar to that of a barrel. This change in chest shape is due to hyperinflation of the lungs, which occurs as a result of air trapping and increased residual volume in the lungs, common in COPD.
Correct Answer is A
Explanation
A. Oral mucosa:
The oral mucosa, including the inside of the mouth, tongue, and lips, is a reliable indicator of cyanosis. Cyanosis appears as a bluish discoloration of these tissues due to decreased oxygen saturation in the arterial blood. Assessing the oral mucosa is an essential component of clinical examination, especially in patients with respiratory conditions like asthma, as it provides valuable information about oxygenation status.
B. Tip of the nose:
While the tip of the nose may exhibit cyanosis in some cases, it is not considered as reliable of an indicator as the oral mucosa. The nasal tip is more susceptible to external factors such as cold temperatures or poor circulation, which can cause temporary discoloration. Therefore, it may not always accurately reflect the oxygenation status of the patient compared to the oral mucosa.
C. Ear lobes:
Cyanosis may be observed in the ear lobes in cases of severe hypoxemia, but it is not as reliable of an indicator as the oral mucosa. The ear lobes are less commonly assessed for cyanosis compared to other areas such as the lips, nail beds, or oral mucosa. While cyanosis may be present in the ear lobes, it is not typically the primary site assessed for oxygenation status.
D. Eyelids:
Cyanosis is not typically observed in the eyelids and is not considered a reliable indicator of hypoxemia. The eyelids are not commonly assessed for cyanosis during clinical examinations. While the conjunctiva (the lining inside the eyelids) may appear pale in cases of severe anemia, it is not a specific sign of hypoxemia. Assessment of the oral mucosa, lips, and nail beds is preferred for evaluating oxygenation status in patients with respiratory conditions like asthma.
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