What findings indicate tension pneumothorax causing mediastinal shift?

Correct Answer: A

Rationale: In tension pneumothorax, the accumulation of air in the pleural space under pressure leads to a mediastinal shift, causing potentially life-threatening complications. Option A is correct because it describes the classic signs of tension pneumothorax: diminished breath sounds on the affected side due to lung collapse, tracheal deviation away from the affected side towards the unaffected side, and hemodynamic instability manifested by decreasing blood pressure and increasing pulse rate. Option B is incorrect because the described signs are more indicative of a simple pneumothorax rather than tension pneumothorax, as tracheal deviation typically occurs towards the affected side. Option C describes findings more consistent with a pulmonary embolism rather than tension pneumothorax. Option D includes signs that are not specific to tension pneumothorax but could be seen in various respiratory or cardiovascular conditions. For nursing students, understanding these distinct clinical manifestations is crucial for prompt recognition and intervention in patients with tension pneumothorax, as timely management can be life-saving. Recognizing the unique signs and symptoms associated with tension pneumothorax is essential for providing safe and effective care to patients in acute care settings.

Correct Answer: B

Rationale: In this scenario, the correct action that assumes the greatest priority for Mr. Walker is option B) Monitor respiratory status for increasing dyspnea. This is because Mr. Walker presents with a productive cough, dull percussion notes, and rhonchi, which are indicative of respiratory distress and potential respiratory infection. Monitoring his respiratory status will help in early detection of any worsening symptoms such as increased dyspnea, which could signal a deterioration in his condition and the need for prompt intervention. Option A) Determine if Mr. Smith has a history of COPD is incorrect as it does not address the immediate need for monitoring and assessing the current respiratory status of Mr. Walker. Option C) Discuss ways to prevent pneumonia is also incorrect as it is a preventive measure and does not address the immediate need for managing Mr. Walker's current respiratory symptoms and potential infection. Option D) Obtain a physician’s order for sedatives is not appropriate in this case as sedatives would not address the underlying respiratory issues causing Mr. Walker's symptoms and could potentially worsen his condition. In an educational context, it is crucial for nursing students to understand the prioritization of nursing actions based on the patient's presenting symptoms and needs. Monitoring respiratory status in a patient with respiratory distress is a critical nursing intervention to ensure timely and appropriate care for the patient. This question highlights the importance of quick and accurate assessment in managing patients with respiratory issues in a medical-surgical nursing setting.

Correct Answer: D

Rationale: The correct nursing action of sitting Mr. Puff up in bed with arms resting on pillows on the overbed table is the most appropriate in the given scenario. This position promotes optimal lung expansion, which can help improve his respiratory effort and oxygenation. By sitting him up, it reduces pressure on his diaphragm, allowing for better lung expansion and oxygen exchange, thus improving his cyanosis and shallow respirations. Option A is incorrect as changing his nasal cannula to a Venturi mask may not address the immediate need for improved oxygenation that sitting him up would provide. Option B of offering water to increase fluid intake is also inappropriate as it does not address the respiratory distress Mr. Puff is experiencing. Option C of walking him in the hall to increase mobility is contraindicated in this situation as his respiratory status needs to be stabilized first before considering ambulation. In an educational context, this scenario highlights the importance of understanding the physiological principles behind positioning for optimal respiratory function in patients experiencing respiratory distress. Nurses must prioritize interventions that address the immediate needs of the patient to ensure their safety and well-being.

Correct Answer: B

Rationale: In assessing Mr. Stout with chronic bronchitis, the presence of a chronic cough (Option B) would be the sign one would expect to find. This is because chronic bronchitis is characterized by inflammation of the bronchial tubes leading to excessive mucus production, resulting in a persistent cough that lasts for at least three months in two consecutive years. Option A, loss of weight, is less specific to chronic bronchitis and can be seen in a variety of health conditions. Option C, barrel chest, is more commonly associated with conditions like emphysema rather than chronic bronchitis. Option D, scanty sputum, is not typical of chronic bronchitis, as this condition is characterized by increased sputum production. In an educational context, understanding the specific signs and symptoms of chronic bronchitis is crucial for nurses to provide accurate assessments, care, and education to patients. By knowing that a chronic cough is a hallmark sign of chronic bronchitis, nurses can intervene appropriately by providing symptom management strategies, patient education on smoking cessation, and promoting respiratory health.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Personal history of allergies. Wendy's asthmatic attack is likely precipitated by her personal history of allergies. Asthma is often triggered by allergens such as pollen, dust mites, or pet dander. Individuals with a history of allergies are more susceptible to developing asthma due to the inflammatory response triggered by allergens in the airways. Option A) Breaking up with her boyfriend is an emotional stressor and can exacerbate asthma symptoms, but it is not the underlying cause of the asthmatic attack. Option C) Restless sleeping pattern may lead to fatigue and stress, which can worsen asthma symptoms, but it is not the direct precipitating cause in this case. Option D) Smoking five cigarettes daily can certainly aggravate asthma symptoms and is a risk factor for developing asthma, but it is not the immediate cause of Wendy's asthmatic attack. Educationally, it is crucial for nursing students to understand the various triggers and risk factors for asthma to provide effective patient care. Recognizing personal history of allergies as a common precipitating cause of asthma attacks enables nurses to implement appropriate interventions such as allergen avoidance, medication management, and patient education to help prevent future exacerbations.