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Patient Data
Exhibits
The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.

Pain level in abdomen and back

Liquid diarrhea

Indigestion

Extremity pulse 2+

Tiredness

Abdominal bruit

Pulsatile mass

Answer and Explanation

Correct Answer : A,F,G

Rationale:
A. Pain level in abdomen and back: Sudden, severe, or worsening abdominal and back pain in an older male with a history of hypertension and a pulsatile abdominal mass is highly suggestive of an expanding or rupturing abdominal aortic aneurysm (AAA). This finding indicates possible vascular compromise and requires immediate evaluation.

B. Liquid diarrhea: Although diarrhea may be uncomfortable, it is not immediately life-threatening and may result from reduced blood flow to the intestines or anxiety. It does not take precedence over findings suggesting a vascular emergency.

C. Indigestion: The client’s indigestion could reflect reduced gastrointestinal perfusion or early aneurysmal pressure, but it is a less specific symptom. It warrants documentation and monitoring but is not an immediate priority compared to the risk of rupture.

D. Extremity pulse 2+: Palpable peripheral pulses indicate adequate distal circulation at the moment and are not concerning for acute compromise. The focus should remain on central findings suggestive of aneurysm instability.

E. Tiredness: Fatigue may be related to cardiac rhythm disturbances or poor perfusion, but it is nonspecific and not an emergent concern in this context. Other critical findings take precedence.

F. Abdominal bruit: A bruit over a pulsatile mass indicates turbulent blood flow within a weakened vessel wall, strongly suggesting an aortic aneurysm. It is an urgent finding that may precede rupture and requires immediate provider notification.

G. Pulsatile mass: The presence of a pulsatile abdominal mass is the most significant physical finding consistent with an abdominal aortic aneurysm. Combined with severe back and abdominal pain, this finding signals a potential rupture risk, necessitating rapid diagnostic imaging and emergency intervention.

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Correct Answer is D

Explanation

Rationale:
A. Position the client for comfort on the nonoperative side: Repositioning may improve comfort but does not address the possible cause of absent fluctuation in the water seal chamber. This intervention would not determine whether the lung has re-expanded or if there is an obstruction in the system.

B. Clamp the tubing and have the client take deep breaths: Clamping the chest tube is contraindicated unless specifically ordered, as it can cause tension pneumothorax by trapping air in the pleural space. Deep breathing will not identify the cause of the lack of fluctuation safely.

C. Increase the amount of suction on the wall suction: Increasing suction arbitrarily may not correct the problem and could damage lung tissue. The absence of fluctuation may be due to re-expansion of the lung or blockage in the tubing, not inadequate suction strength.

D. Assess the client’s breath sounds on the affected lung: Assessing breath sounds helps determine whether the lung has fully re-expanded or if the chest tube is obstructed. If breath sounds are equal bilaterally and the client shows no respiratory distress, the lack of fluctuation likely indicates lung re-expansion, a positive outcome.

A. Flushed face. B. Urinary urgency. C. Pain. D. Pale lower extremity. E. Bradycardia.

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

Explanation

Rationale:
A. Flushed face: Autonomic dysreflexia causes an exaggerated sympathetic response below the level of injury and a parasympathetic response above it. Vasodilation above the injury leads to facial flushing, nasal congestion, and a warm sensation in the upper body.

B. Urinary urgency: The client typically cannot sense bladder fullness due to spinal cord disruption. Instead, bladder distention acts as the trigger for autonomic dysreflexia, but the client does not perceive urgency because of impaired sensation below the injury level.

C. Pain: Clients with high thoracic or cervical spinal cord injuries do not feel pain below the level of injury. Although pain can sometimes precipitate autonomic dysreflexia, the condition itself does not cause a conscious pain sensation.

D. Pale lower extremity: Vasoconstriction occurs below the level of injury due to excessive sympathetic discharge. This results in cool, pale skin and decreased perfusion in the lower extremities while the upper body shows flushing.

E. Bradycardia: The baroreceptor reflex activates parasympathetic stimulation in response to severe hypertension, resulting in reflex bradycardia. This slowed heart rate is a hallmark feature of autonomic dysreflexia and helps differentiate it from other hypertensive crises.

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Patient Data Exhibits The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.

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Naxlex Comprehensive Predictor Exams

Four days ago, a chest tube was inserted into the second intercostal space (ICS) of a client with a pneumothorax. Today the nurse notes that there is no fluctuation in the water seal chamber of the chest tube drainage system. Which intervention should the nurse implement next?

Correct Answer is D

Explanation

A week after a client suffered a high thoracic spinal cord injury in a motor vehicle collision, the blood pressure suddenly rises to 196/126 mm Hg. Which physiological sign(s) should the nurse identify that the client is exhibiting autonomic dysreflexia? select all that apply.

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

Explanation

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Patient Data
Exhibits
The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.