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Exhibits
The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Bone misalignment

Decreased range of motion

Left arm that is cool to touch

Swelling at the site of injury

Blood pressure of 136/90 mm Hg

Intense pain reported by client

Oxygen saturation 95% on room air

Answer and Explanation

Correct Answer : A,B,C,D,F

A. Bone misalignment - The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.

B. Decreased range of motion - The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.

C. Left arm that is cool to touch - Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.

D. Swelling at the site of injury - Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.

E. Blood pressure of 136/90 mm Hg - While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.

F. Intense pain reported by client - The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.

G. Oxygen saturation 95% on room air - While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.

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Correct Answer is B

Explanation

Choice A rationale

Production of extra platelets is not the primary pathophysiological process in Disseminated Intravascular Coagulation (DIC). While the body may try to produce more platelets in response to the widespread clotting, this is not the cause of the coagulation problem.

Choice B rationale

Depletion of clotting factors is a key feature of DIC. In the initial phase of DIC, there is an overactive clotting process leading to the formation of small blood clots throughout the body’s blood vessels. This overactive clotting uses up platelets and clotting factors, leading to a state where the body is unable to control bleeding, which is the second phase of DIC34.

Choice C rationale

Inhibition of red blood cell production is not a primary feature of DIC. While DIC can lead to anemia due to blood loss from excessive bleeding, it does not directly inhibit the production of red blood cells.

Choice D rationale

Activation of complement pathways is part of the body’s immune response and is not the primary cause of the coagulation problem in DIC34.

A. Diaphragmatic respirations. B. Resting respiratory rate of 35 breaths/min. C. Bilateral bronchial breath sounds. D. Flaring of the nares.

Correct Answer is D

Explanation

Choice A rationale

Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.

Choice B rationale

A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.

Choice C rationale

Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.

Choice D rationale

Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.

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Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with septic shock develops Disseminated Intravascular Coagulation (DIC). Which pathophysiological process should the nurse identify as the cause of the coagulation problem?

Correct Answer is B

Explanation

A parent brings a 4-month-old infant to the clinic.The infant has had a runny nose, a slight fever, and a cough for the last two days.Which of the following findings should alert the nurse that the child is in acute respiratory distress?

Correct Answer is D

Explanation

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Exhibits
The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.