The nurse provides care for a client immediately after a motor vehicle accident. The nurse notes BP 90/52 mmHg, absent breath sounds over the right lung, shallow RR 28 breaths/minute, and displacement of the trachea to the left side. Which explanation is correct for these findings?

Hemothorax

Absorption atelectasis

Tension pneumothorax

Hypovolemic shock

Answer and Explanation

The Correct Answer is C

Choice A reason: Hemothorax is not the correct explanation because it is a condition where blood accumulates in the pleural space, which is the area between the lungs and the chest wall. Hemothorax can cause low blood pressure, rapid breathing, and reduced breath sounds, but it does not cause tracheal deviation, which is a sign of increased pressure in the chest.

Choice B reason: Absorption atelectasis is not the correct explanation because it is a condition where the alveoli, which are the tiny air sacs in the lungs, collapse due to lack of oxygen. Absorption atelectasis can cause reduced breath sounds, but it does not cause low blood pressure, rapid breathing, or tracheal deviation, which are signs of a life-threatening emergency.

Choice C reason: Tension pneumothorax is the correct explanation because it is a condition where air leaks into the pleural space and creates a one-way valve that prevents the air from escaping. This causes the pressure in the chest to increase, which compresses the lung, the heart, and the great vessels. Tension pneumothorax can cause low blood pressure, rapid breathing, absent breath sounds, and tracheal deviation, which are signs of a medical emergency that requires immediate treatment.

Choice D reason: Hypovolemic shock is not the correct explanation because it is a condition where the body loses a large amount of blood or fluid, which reduces the blood volume and the blood pressure. Hypovolemic shock can cause low blood pressure and rapid breathing, but it does not cause absent breath sounds or tracheal deviation, which are signs of a chest injury.

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Correct Answer is C

Explanation

Choice A reason: Muscle weakness and motor seizures are not the most serious complication because they are signs of electrolyte imbalance, not urinary tract infection. Electrolyte imbalance is a condition where the levels of minerals and salts in the blood are too high or too low, which can affect the nerve and muscle function, causing symptoms such as weakness, spasms, or seizures. Electrolyte imbalance can be caused by various factors, such as dehydration, kidney failure, or medications.

Choice B reason: Upper abdominal pain and cramping are not the most serious complication because they are signs of gastritis, not urinary tract infection. Gastritis is a condition where the lining of the stomach is inflamed, causing symptoms such as pain, nausea, or vomiting. Gastritis can be caused by various factors, such as infections, stress, or medications.

Choice C reason: Confusion and agitation are the most serious complication because they are signs of sepsis, which is a life-threatening condition where the body's response to an infection causes widespread inflammation and organ damage. Sepsis can be caused by various types of infections, including urinary tract infection, which is an infection that affects the bladder, urethra, or kidneys. Sepsis can cause symptoms such as confusion, agitation, fever, chills, or shock.

Choice D reason: Periorbital edema and cardiac dysrhythmias are not the most serious complication because they are signs of heart failure, not urinary tract infection. Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs, causing symptoms such as swelling, shortness of breath, or irregular heartbeat. Heart failure can be caused by various factors, such as coronary artery disease, hypertension, or diabetes.

A. Infected macrophages and lymphocytes surround the Mycobacterium tuberculosis bacteria and form a tuberculous granuloma. B. Tumor necrosis factor is released by T lymphocytes and lyses the Mycobacterium tuberculosis bacteria in the alveoli. C. Natural killer cells and neutrophils form a thick purulent debris, which becomes a caseous necrosis. D. The inflammatory response of cytokines activates the complement system and causes permanent lung tissue damage.

Correct Answer is A

Explanation

Choice A reason: Infected macrophages and lymphocytes surround the Mycobacterium tuberculosis bacteria and form a tuberculous granuloma is the best explanation for the primary immune response to tuberculosis infection. A granuloma is a collection of immune cells that wall off the bacteria and prevent their spread. It is a protective mechanism that limits the infection and preserves the lung function.

Choice B reason: Tumor necrosis factor is released by T lymphocytes and lyses the Mycobacterium tuberculosis bacteria in the alveoli is not a correct explanation for the primary immune response to tuberculosis infection. Tumor necrosis factor is a cytokine that activates macrophages and induces inflammation, but it does not directly kill the bacteria. It may also have harmful effects by causing tissue damage and weight loss.

Choice C reason: Natural killer cells and neutrophils form a thick purulent debris, which becomes a caseous necrosis is not a correct explanation for the primary immune response to tuberculosis infection. Natural killer cells and neutrophils are part of the innate immune system, which is not very effective against intracellular bacteria like Mycobacterium tuberculosis. Caseous necrosis is a type of tissue death that results from the liquefaction of the granuloma. It is a sign of progressive disease, not primary infection.

Choice D reason: The inflammatory response of cytokines activates the complement system and causes permanent lung tissue damage is not a correct explanation for the primary immune response to tuberculosis infection. The inflammatory response of cytokines and the complement system are part of the innate immune system, which is not very effective against intracellular bacteria like Mycobacterium tuberculosis. Permanent lung tissue damage is a complication of chronic or reactivated tuberculosis, not primary infection.

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The nurse provides care for a client immediately after a motor vehicle accident. The nurse notes BP 90/52 mmHg, absent breath sounds over the right lung, shallow RR 28 breaths/minute, and displacement of the trachea to the left side. Which explanation is correct for these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is diagnosed with a severe urinary tract infection. The nurse assesses the client for which most serious complication?

Correct Answer is C

Explanation

The nurse cares for the client with a history of pulmonary tuberculosis (TB). Two granulomas were present in the chest x-ray. Which explanation does the nurse understand best describes the primary immune response to tuberculosis infection?

Correct Answer is A

Explanation

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