Which of the following could the nurse expect to observe in an older adult client who has a pneumothorax?
Higher oxygen saturations of 98% to 99%
Lower oxygen saturations of 93% to 94%
Lower energy expenditure
Increased lung capacity
The Correct Answer is B
Choice A Reason:
Higher oxygen saturations of 98% to 99% is inappropriate. A pneumothorax involves the presence of air in the pleural space, which can compromise lung function and gas exchange. This compromised lung function typically leads to decreased oxygenation of the blood, resulting in lower oxygen saturations rather than higher saturations.
Choice B Reason:
Lower oxygen saturations of 93% to 94% is appropriate. A pneumothorax disrupts the normal exchange of oxygen and carbon dioxide in the lungs due to partial or complete lung collapse. As a result, the affected lung is unable to adequately oxygenate the blood, leading to lower oxygen saturations, which are indicative of hypoxemia.
Choice C Reason:
Lower energy expenditure is inappropriate. Energy expenditure is not typically affected by a pneumothorax. While the discomfort and respiratory distress associated with a pneumothorax may cause the individual to limit physical activity, there is no direct impact on overall energy expenditure.
Choice D Reason:
Increased lung capacity is inappropriate. A pneumothorax results in partial or complete collapse of the affected lung, reducing lung capacity rather than increasing it. The presence of air in the pleural space creates positive pressure, which can compress the lung and decrease its ability to expand fully during inhalation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A Reason:
Metoprolol is incorrect. Metoprolol is a beta-blocker medication commonly used to treat conditions such as hypertension, angina, and heart failure. However, in the context of neurogenic shock following a spinal cord injury, the use of beta-blockers such as metoprolol is generally contraindicated. Beta-blockers antagonize the effects of sympathetic activation, leading to a reduction in heart rate and myocardial contractility, which can exacerbate hypotension and bradycardia, the hallmarks of neurogenic shock. Therefore, the nurse would not anticipate a prescription for metoprolol in the management of neurogenic shock.
Choice B Reason:
Lactated Ringers intravenous fluid is correct. Fluid resuscitation with isotonic crystalloid solutions such as lactated Ringers is essential to restore intravascular volume and improve perfusion.
Choice C Reason:
Furosemide is incorrect. Furosemide is a loop diuretic medication commonly used to treat conditions such as heart failure, edema, and hypertension by promoting diuresis and reducing fluid volume. However, in the context of neurogenic shock, the use of diuretics such as furosemide is generally not indicated unless there is concurrent volume overload. Neurogenic shock is characterized by hypotension due to vasodilation and decreased systemic vascular resistance, often leading to relative hypovolemia rather than volume overload. Therefore, administering furosemide could further decrease intravascular volume, exacerbating hypotension and compromising perfusion. As a result, the nurse would not anticipate a prescription for furosemide in the management of neurogenic shock.:
Choice D Reason:
Dopamine is correct. Dopamine is a vasopressor medication that acts to increase vascular tone and blood pressure by stimulating alpha-adrenergic receptors. It is commonly used in the management of neurogenic shock to augment blood pressure.
Choice E Reason:
Epinephrine is correct. Epinephrine is a potent vasopressor that acts on both alpha and beta-adrenergic receptors, leading to vasoconstriction and increased cardiac output. It is used in the treatment of refractory hypotension in neurogenic shock.
Correct Answer is ["A","D","E"]
Explanation
Choice A Reason:
"Are you having any feelings of depression?". This statement is appropriate. Migraines can significantly impact mood, and depression is a common comorbidity in individuals with chronic migraines. Inquiring about feelings of depression allows the nurse to assess the client's mental health status and provide appropriate support or referrals if needed.
Choice B Reason:
"Are you experiencing any sensitivity to light?": This statement is inappropriate. This question addresses a physical symptom commonly associated with migraines rather than psychosocial impact.
Choice C Reason:
"Are you feeling any increase in your sexual drive?"Migraines are more likely to decrease sexual drive due to pain and fatigue. This question is not typically relevant to the psychosocial impact of migraines.
Choice D Reason:
"Are you experiencing any episodes of 'panic-type' feelings?" This statement is appropriate. Migraines can sometimes trigger anxiety or panic attacks in affected individuals. Inquiring about panic-type feelings allows the nurse to assess the client's emotional response to migraines and provide interventions or referrals for anxiety management if necessary.
Choice E Reason:
"Are you experiencing more fatigue as compared to before you had migraines?": This statement is appropriate. Fatigue is a common symptom associated with migraines, both during and after an attack. Assessing the client's level of fatigue helps the nurse understand the impact of migraines on the client's energy levels and overall functioning.
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