A 40-year-old patient is admitted with sharp, pleuritic chest pain and dyspnea. The nurse observes jugular venous distension and muffled heart sounds on examination. What is the most appropriate initial nursing action for this patient?

Encouraging the patient to take deep breaths and cough

Administering oxygen to maintain adequate oxygenation

Positioning the patient flat in bed to decrease discomfort

Providing the patient with a warm compress to relieve chest pain

Positive Tinel's sign

Answer and Explanation

The Correct Answer is B

A.   Encouraging the patient to take deep breaths and cough would not address the underlying cause of the symptoms, which may indicate a more serious condition.
B.   Administering oxygen to maintain adequate oxygenation is the most appropriate initial action, as the patient’s symptoms suggest a potentially life-threatening condition like a cardiac tamponade or pulmonary embolism.
C.   Positioning the patient flat in bed is not recommended, as it may exacerbate breathing difficulties and
the patient’s distress.
D.   A warm compress is unlikely to be beneficial in this acute situation and could delay appropriate intervention.

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Correct Answer is C

Explanation

A. Airway obstruction in asthma is not caused by thinning mucus. It is primarily due to bronchospasm, inflammation, and thickening of the mucus.
B. Decreased mucus production does not contribute to airway constriction in asthma. In fact, excessive mucus production is a key feature of asthma, leading to obstruction of the airways.
C. Bronchospasm in asthma involves inflammation, edema, and excess mucus production. These factors cause narrowing of the airways, leading to difficulty breathing.
D. Inflammation leads to airway narrowing, but it does not reduce the airway diameter in the sense of preventing bronchospasm. Bronchospasm occurs as a result of inflammation and muscle contraction.

A. Peptic ulcer disease B. Acute gastritis due to NSAID use C. Functional dyspepsia D. Chronic gastritis due to Helicobacter pylori infection

Correct Answer is D

Explanation

A. Peptic ulcer disease is possible, but the patient's NSAID use and positive H. pylori antibodies suggest a more specific cause related to gastritis.
B. Acute gastritis due to NSAID use is likely since NSAIDs can irritate the stomach lining and increase the risk of ulcers.
C. Functional dyspepsia is less likely given the presence of H. pylori antibodies, which typically indicate an active infection.
D. Chronic gastritis due to Helicobacter pylori infection is the most likely diagnosis, especially with the combination of NSAID use and positive H. pylori antibodies.

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A 40-year-old patient is admitted with sharp, pleuritic chest pain and dyspnea. The nurse observes jugular venous distension and muffled heart sounds on examination. What is the most appropriate initial nursing action for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with asthma. Which of the following happens physiologically when bronchospasm occurs?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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