Which of the following are signs of a tension pneumothorax?

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Fundamentals Wound Care and Skin Integrity Questions Questions

Question 1 of 5

Which of the following are signs of a tension pneumothorax?

Correct Answer: A

Rationale: Dyspnea is a sign of tension pneumothorax.

Question 2 of 5

The hospice nurse is working with the family of a 30-year-old client who is dying. The client voices concerns about how her death will be perceived by her 7-year-old child. What advice from the nurse would be most beneficial?

Correct Answer: B

Rationale: Children at age 7 understand the finality of death. This knowledge can help the client address her child's perception appropriately.

Question 3 of 5

A client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting would have which nursing diagnosis as a first priority?

Correct Answer: B

Rationale: Symptoms of Meniere's disease indicate a high risk for falls due to imbalance, making 'Trauma, Risk for' the top priority for safety.

Question 4 of 5

A client recently diagnosed with herpes simplex II asks how to best manage the lesions. What information should be given to the client?

Correct Answer: D

Rationale: Lesions should be kept clean and dry with gentle soap and water. Alcohol burns, and nylon retains moisture, worsening discomfort.

Question 5 of 5

Which finding requires immediate referral when a nurse assesses an older adult's skin?

Correct Answer: B

Rationale: The lesion with various colors fits one of the American Cancer Society hallmark signs for cancer according to the ABCD method (color variation). This requires immediate referral.

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