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 B

Explanation

Choice A reason: Glomerulonephritis is an inflammation of the glomeruli, the filtering units of the kidneys. It can cause damage to the renal tissue and lead to intrinsic acute kidney injury, not prerenal acute kidney injury.

Choice B reason: Fluid volume deficit is a condition in which the body loses more fluid than it takes in. It can cause hypovolemia, which reduces the blood flow to the kidneys and impairs their function. This is the most common cause of prerenal acute kidney injury, which is a result of decreased perfusion to the kidneys.

Choice C reason: Neurogenic bladder is a dysfunction of the bladder caused by a nerve problem. It can affect the ability to store or empty urine. It can cause urinary retention, which increases the pressure in the urinary tract and damages the kidneys. This is a type of postrenal acute kidney injury, which is a result of obstruction to the urine outflow.

Choice D reason: Renal calculus is a solid mass formed from crystals in the urine. It can block the ureter, the tube that carries urine from the kidney to the bladder. It can cause hydronephrosis, which is a swelling of the kidney due to accumulation of urine. This is another type of postrenal acute kidney injury.

A. Hepatomegaly B. Abdominal cramping pain C. Whitish patches on the tongue D. Arthritis with papular rash

Correct Answer is D

Explanation

Choice A reason: Hepatomegaly is not the expected finding because it is a condition where the liver is enlarged, which can be caused by various factors, such as infections, tumors, or cirrhosis. Hepatomegaly is not a common manifestation of systemic lupus erythematosus, which is an autoimmune disease that causes inflammation and damage to various organs and tissues in the body.

Choice B reason: Abdominal cramping pain is not the expected finding because it is a symptom that can be caused by various conditions, such as irritable bowel syndrome, appendicitis, or diverticulitis. Abdominal cramping pain is not a specific manifestation of systemic lupus erythematosus, although some clients may experience abdominal discomfort due to gastritis, pancreatitis, or peritonitis, which are possible complications of the disease.

Choice C reason: Whitish patches on the tongue are not the expected finding because they are a sign of oral candidiasis, which is a fungal infection that affects the mouth and throat. Oral candidiasis can be caused by various factors, such as weakened immune system, antibiotic use, or diabetes. Oral candidiasis is not a typical manifestation of systemic lupus erythematosus, although some clients may have oral ulcers, which are painful sores that appear on the lips, gums, or tongue.

Choice D reason: Arthritis with papular rash is the expected finding because it is a characteristic manifestation of systemic lupus erythematosus, which affects the joints and the skin. Arthritis is a condition where the joints are inflamed, causing pain, stiffness, and swelling. Arthritis can affect any joint in the body, but it is more common in the hands, wrists, and knees. Papular rash is a type of skin rash that consists of small, raised bumps that are red or purple. Papular rash can appear on any part of the body, but it is more common on the face, especially on the cheeks and the bridge of the nose. Papular rash is also known as malar rash or butterfly rash, because of its shape and location.

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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

Which risk factor is significant for the development of prerenal acute kidney injury?

Correct Answer is B

Explanation

The nurse provides care for a client diagnosed with systemic lupus erythematosus. Which finding does the nurse expect to assess?

Correct Answer is D

Explanation

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