While caring for a client who was injured in a motor-vehicle crash and reports dyspnea and severe pain, a nurse in the emergency department notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

Correct Answer: B

Rationale: The correct answer is B: Flail chest. Flail chest occurs when a segment of the rib cage is detached from the rest of the chest wall, causing paradoxical chest movement. In this case, the inward movement during inspiration and outward bulging during expiration are classic signs of flail chest, as the detached segment moves in the opposite direction of the rest of the chest wall. Atelectasis (choice A) refers to collapsed lung tissue, not paradoxical chest movement. Hemothorax (choice C) is the accumulation of blood in the pleural space, which does not cause paradoxical chest movement. Pneumothorax (choice D) is the presence of air in the pleural space, which can cause chest pain and dyspnea but does not result in paradoxical chest movement.

Correct Answer: A

Rationale: Aging-related changes include decreased appetite, reduced muscle mass, impaired balance, and increased bladder sensitivity—all contributing to various nursing diagnoses.

Correct Answer: D

Rationale: Clients may overeat or lose appetite due to stress, affecting their weight and overall health.

Correct Answer: D

Rationale: Filtration involves the movement of fluid and solutes across a semipermeable membrane due to hydrostatic or osmotic pressure differences.

Correct Answer: D

Rationale: Fetal heart sounds are a definitive sign of pregnancy, confirming the presence of a viable fetus.

Correct Answer: D

Rationale: The correct answer is D: Hemodynamic status. A pulmonary artery catheter is used to monitor hemodynamic parameters such as cardiac output, pulmonary artery pressure, and central venous pressure. This helps assess the patient's circulatory status and guide interventions in critically ill patients. Explanation: 1. Pulmonary artery catheter measures cardiac output and helps in assessing the heart's ability to pump blood effectively. 2. It provides information on pulmonary artery pressure which reflects the pressure in the right side of the heart and pulmonary circulation. 3. Central venous pressure is also monitored, indicating the fluid status and right heart function. Summary: A: Intracranial pressure - Incorrect. Pulmonary artery catheter does not monitor intracranial pressure. B: Spinal cord perfusion - Incorrect. Pulmonary artery catheter does not monitor spinal cord perfusion. C: Renal function - Incorrect. Pulmonary artery catheter does not monitor renal function.

Correct Answer: B

Rationale: Middle age often involves re-evaluating personal relationships.

Correct Answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, harsh respiratory sound that indicates airway obstruction, which can be life-threatening post endotracheal tube removal. Copious oral secretions (B), hoarseness (C), and sore throat (D) are common after endotracheal tube removal but do not indicate immediate airway compromise. Reporting stridor is crucial for prompt intervention to prevent respiratory distress.

Correct Answer: B

Rationale: In many Asian cultures, avoiding direct eye contact signifies respect, particularly toward authority figures or elders.