The nurse is assessing the respiratory status of a client who has suffered a fractured rib. Which observation, if made by the nurse, would not be directly related to the fractured rib?
Pleural effusion on the unaffected side
Shallow breathing due to pain
Guarding behavior when taking deep breaths
Localized chest pain on inspiration
The Correct Answer is A
A. Pleural effusion on the unaffected side is not directly related to a fractured rib. While rib fractures can lead to complications such as pneumothorax or hemothorax, pleural effusion on the opposite side is likely caused by another condition, such as infection or malignancy, and should be investigated separately.
B. Shallow breathing due to pain is a common response to a fractured rib, as the client may avoid deep breaths to minimize discomfort.
C. Guarding behavior when taking deep breaths is directly related to the pain caused by the fractured rib and is an expected observation.
D. Localized chest pain on inspiration is a hallmark symptom of a fractured rib, as the injury causes discomfort with chest wall movement during breathing.
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Related Questions
Correct Answer is C
Explanation
A. Metabolic alkalosis is not typically associated with COPD. This condition is more commonly seen in situations involving excessive vomiting, diuretic use, or certain metabolic disorders.
B. Respiratory alkalosis is not expected in COPD. In COPD, the patient often retains carbon dioxide due to impaired gas exchange, leading to respiratory acidosis rather than alkalosis.
C. Respiratory acidosis is the most common acid-base imbalance in COPD. Due to the inability to effectively exhale carbon dioxide, patients with COPD often develop hypercapnia (elevated CO2 levels), leading to respiratory acidosis. This is particularly common during exacerbations when the patient is short of breath and unable to clear CO2 adequately.
D. Metabolic acidosis is not typically associated with COPD. While it can occur in certain conditions like renal failure or diabetic ketoacidosis, it is not a primary concern in COPD exacerbations. Respiratory acidosis is the more likely finding.
Correct Answer is A
Explanation
A. Pleural effusion on the unaffected side is not directly related to a fractured rib. While rib fractures can lead to complications such as pneumothorax or hemothorax, pleural effusion on the opposite side is likely caused by another condition, such as infection or malignancy, and should be investigated separately.
B. Shallow breathing due to pain is a common response to a fractured rib, as the client may avoid deep breaths to minimize discomfort.
C. Guarding behavior when taking deep breaths is directly related to the pain caused by the fractured rib and is an expected observation.
D. Localized chest pain on inspiration is a hallmark symptom of a fractured rib, as the injury causes discomfort with chest wall movement during breathing.
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