The nurse is providing care to a client with a suspected pulmonary embolism. Which of the following is not a manifestation of a pulmonary embolism?
Hemoptysis
Petechiae
Tachycardia
Facial weakness
The Correct Answer is D
A. Hemoptysis (coughing up blood) is a known symptom of a pulmonary embolism (PE). It results from lung tissue damage due to obstructed blood flow.
B. Petechiae are not typically associated with a PE. They are more commonly linked to conditions such as thrombocytopenia or fat embolism syndrome.
C. Tachycardia is a common manifestation of a PE. The heart rate increases as a compensatory mechanism due to decreased oxygenation.
D. Facial weakness is not a typical sign of PE. It is more commonly associated with conditions like stroke or Bell's palsy.
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Related Questions
Correct Answer is C
Explanation
A. A complete occlusion of the coronary artery is characteristic of an ST-segment elevation myocardial infarction (STEMI), not an NSTEMI.
B. Chest pain that resolves with rest is more indicative of stable angina rather than NSTEMI.
C. An NSTEMI occurs due to a partial occlusion of a coronary artery, leading to myocardial ischemia and damage without ST-segment elevation on an ECG.
D. Chest pain at rest can be seen in both unstable angina and NSTEMI, but it is not the defining feature of NSTEMI.
Correct Answer is C
Explanation
A. Encouraging increased fluid intake is incorrect. Clients with heart failure are at risk for fluid overload, and excessive fluid intake can worsen symptoms.
B. Simply monitoring and documenting findings is insufficient. A 2-pound weight gain in a short period suggests fluid retention and worsening heart failure, requiring further assessment and possible intervention.
C. Performing a head-to-toe assessment, including vital signs, is correct. The nurse should assess for worsening heart failure, including lung sounds (crackles), respiratory effort, blood pressure, and oxygen saturation, to determine if immediate interventions are needed.
D. Checking code status is not the priority. While knowing a client’s code status is important, the immediate concern is assessing for signs of fluid overload and potential decompensation.
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