The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?

Correct Answer: A

Rationale: Post-trauma symptoms like increased accessory muscle use, chest pain, and shortness of breath suggest a pneumothorax, where air in the pleural space collapses the lung, impairing ventilation. Accessory muscles (e.g., sternocleidomastoid) compensate for reduced lung expansion, while pain arises from pleural irritation or rib fractures, common in motor vehicle accidents. Anxiety may cause rapid breathing, but chest pain and accessory muscle use are less typical unless panic mimics trauma effects, which history rules out. Acute bronchitis, an inflammatory condition, presents with cough and mucus, not trauma-related dyspnea or pain. Aspiration involves inhaling foreign material, causing cough or infection, not immediate post-accident symptoms. The nurse's recognition of pneumothorax prompts urgent imaging (e.g., chest X-ray) and intervention (e.g., chest tube), critical given its potential to progress to tension pneumothorax in a trauma setting.

Correct Answer: B

Rationale: Alpha1-antitrypsin (AAT) deficiency predisposes young adults to lobular emphysema, a form of COPD, by impairing lung protection. AAT, a protease inhibitor, neutralizes neutrophil elastase, which otherwise degrades alveolar elastin unchecked in deficiency states, causing early-onset emphysema, often sans smoking. This destruction yields air trapping and hyperinflation, hallmarks of lobular emphysema, typically in the lower lobes. Pulmonary edema, fluid in alveoli, stems from cardiac failure or ARDS, not AAT loss. Cystic fibrosis involves CFTR mutations, not AAT, affecting mucus viscosity. Empyema, pleural infection, isn't linked to AAT deficiency. The nurse's recognition of this genetic risk confirmed by AAT levels guides monitoring (e.g., spirometry) and counseling (e.g., avoiding smoke), critical for delaying progression in this rare, inherited condition.

Correct Answer: D

Rationale: In bronchiectasis, clubbing of the fingers is a likely finding for documentation, resulting from chronic hypoxia as dilated bronchi impair gas exchange. This physical sign widened, rounded fingertips reflects prolonged respiratory insufficiency from copious sputum and recurrent infections, common in this condition. Sudden pleuritic chest pain suggests pulmonary embolism or pleurisy, not bronchiectasis's chronic course. Wheezes indicate bronchospasm, typical in asthma, not the wet cough of bronchiectasis. Increased A-P diameter (barrel chest) occurs in COPD's emphysema, not bronchiectasis's bronchial dilation. The nurse's note on clubbing observed via inspection captures a key clinical feature, aiding diagnosis tracking and care planning (e.g., oxygen needs) for this irreversible airway disease.

Correct Answer: A

Rationale: In bronchiectasis care, the nurse prioritizes the patient successfully mobilizing pulmonary secretions, addressing the disease's core issue chronic bronchial dilation trapping thick, purulent mucus. Effective clearance via chest physiotherapy or postural drainage reduces infection risk, obstruction, and dyspnea, improving ventilation and quality of life in this irreversible condition. Maintaining 98% oxygen saturation is unrealistic 90-94% often suffices in chronic lung disease and not the primary focus. Reducing pulmonary blood pressure isn't a bronchiectasis hallmark; it's more relevant in cor pulmonale or pulmonary hypertension. Resuming prediagnosis function in 72 hours is unfeasible given bronchiectasis's permanence. The nurse's goal of secretion mobilization tracked by sputum volume drives symptom relief, aligning with evidence-based management.

Correct Answer: B

Rationale: Moderate sedation, or conscious sedation, is used for procedures like colonoscopies, inducing a depressed level of consciousness where patients remain responsive but relaxed, reducing anxiety and discomfort without full anesthesia. It's not tied to outpatient status many outpatient procedures use local or no sedation. Loss of sensation requires regional anesthesia, like a nerve block, not moderate sedation, which preserves sensation. Immobility is achieved with general anesthesia, not this lighter state where patients can still move. This sedation level allows quick recovery, ideal for ambulatory settings, while maintaining airway control. The nurse's understanding ensures proper monitoring for oversedation risks, aligning with safe administration to achieve the intended conscious yet calm state during the procedure.