The nurse is caring for a client with Mediastinal Lymphadenopathy who has developed a sudden onset of shortness of breath, head swelling, swelling of the eyes, neck and arms, and a severe headache.
The nurse should recognize that which is the presenting emergent condition?

Pulmonary hypertension.

Tumor lysis syndrome.

Pulmonary edema.

Superior vena cava syndrome.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Pulmonary hypertension is characterized by elevated pressures in the pulmonary arteries, leading to symptoms like dyspnea and fatigue, but typically not sudden onset of head, eye, neck, and arm swelling. The described symptoms are more indicative of venous obstruction rather than elevated arterial pressure.

Choice B rationale

Tumor lysis syndrome is a metabolic emergency resulting from rapid breakdown of malignant cells, releasing intracellular contents. It causes hyperkalemia, hyperphosphatemia, and hyperuricemia, leading to renal failure and cardiac arrhythmias, but not typically the localized swelling described.

Choice C rationale

Pulmonary edema involves fluid accumulation in the lung parenchyma, primarily causing severe dyspnea, orthopnea, and crackles. While it can lead to respiratory distress, it does not explain the specific constellation of head, eye, neck, and arm swelling, which points to a different obstructive process.

Choice D rationale

Superior vena cava syndrome (SVCS) is an emergent condition caused by obstruction of the superior vena cava, often by mediastinal tumors. The described symptoms—sudden shortness of breath, head swelling, swelling of the eyes, neck, and arms, and severe headache—are classic manifestations due to impaired venous return from the head, neck, and upper extremities.

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Correct Answer is B

Explanation

Choice A rationale

A review of chest x-ray is primarily used to assess pulmonary status or thoracic aortic issues. While a client with an AAA may have concurrent cardiopulmonary conditions, it is not the immediate priority for an abdominal aneurysm where rupture risk is a significant concern.

Choice B rationale

Assessment of blood pressure is the priority because uncontrolled hypertension is a major risk factor for abdominal aortic aneurysm expansion and rupture. Monitoring blood pressure allows for timely intervention to reduce arterial wall stress and prevent a life-threatening event. A normal range is 120/80 mm Hg.

Choice C rationale

Deep palpation of the abdomen is contraindicated in a client with a known abdominal aortic aneurysm due to the significant risk of aneurysm rupture. Palpation can increase intra-abdominal pressure or directly stress the weakened aortic wall, potentially leading to a catastrophic hemorrhage.

Choice D rationale

Assessing the client's pain is important for comfort and to identify potential complications, but it is not the immediate priority over monitoring for signs of rupture. While severe abdominal or back pain can indicate an impending rupture, direct physiological parameters like blood pressure are more critical for immediate risk assessment.

A. Metabolic alkalosis. B. Hypernatremia. C. Hyperkalemia. D. Decreasing hematocrit.

Correct Answer is C

Explanation

Choice A rationale

Metabolic alkalosis is characterized by an elevated blood pH and bicarbonate levels. In the emergent phase of burn shock, extensive tissue damage releases cellular contents, including acids, and the body's compensatory mechanisms typically involve bicarbonate buffering. However, the primary physiological derangement is often metabolic acidosis due to hypoperfusion and anaerobic metabolism, not alkalosis. Normal arterial pH is 7.35-7.45.

Choice B rationale

Hypernatremia, an elevated serum sodium concentration (normal range 135-145 mEq/L), is not typically seen in the initial phase of burn shock. Instead, there is often significant fluid loss from the intravascular space into the interstitial space due to increased capillary permeability. This fluid shift usually leads to hyponatremia as sodium is diluted by the administration of hypotonic intravenous fluids.

Choice C rationale

Hyperkalemia, an elevated serum potassium concentration (normal range 3.5-5.0 mEq/L), is a common and critical abnormality in the emergent phase of thermal burns. Extensive cellular destruction from the burn injury causes the release of intracellular potassium into the extracellular fluid. This can lead to life-threatening cardiac dysrhythmias due to altered myocardial excitability.

Choice D rationale

A decreasing hematocrit, the percentage of red blood cells in the blood (normal range for males 40-54%, females 36-48%), is not typical in the initial emergent phase of burn shock. While fluid shifts out of the vasculature occur, leading to hypovolemia, the loss is primarily plasma. This results in hemoconcentration, increasing the hematocrit due to relative red blood cell elevation.

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The nurse is caring for a client with Mediastinal Lymphadenopathy who has developed a sudden onset of shortness of breath, head swelling, swelling of the eyes, neck and arms, and a severe headache. The nurse should recognize that which is the presenting emergent condition?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a history of an abdominal aortic aneurysm (AAA). Which of the following assessments should be the nurse's priority for a client with an Abdominal Aortic Aneurysm?

Correct Answer is B

Explanation

The nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock, the nurse should closely monitor for which abnormal laboratory result?

Correct Answer is C

Explanation

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The nurse is caring for a client with Mediastinal Lymphadenopathy who has developed a sudden onset of shortness of breath, head swelling, swelling of the eyes, neck and arms, and a severe headache.
The nurse should recognize that which is the presenting emergent condition?