A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

Respiratory alkalosis

Increased venous return

Decreased cardiac output

Dilated ventricles

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Respiratory alkalosis is incorrect. Tension pneumothorax typically leads to respiratory distress and hypoxemia rather than respiratory alkalosis. The respiratory alkalosis may occur initially due to hyperventilation in response to hypoxemia but would not be directly related to tracheal deviation.

Choice B Reason:

Increased venous return is incorrect. Tension pneumothorax actually leads to decreased venous return due to compression of the great vessels in the thorax, particularly the superior vena cava and the inferior vena cava. This compression results from the increased pressure within the thorax, which impedes blood flow back to the heart.

Choice C Reason:

Decreased cardiac output is incorrect. Tension pneumothorax can indeed lead to decreased cardiac output due to compression of the heart and the great vessels by the accumulating air in the pleural space. This compression decreases venous return and impairs cardiac function.

Choice D Reason:

Dilated ventricles is incorrect. As mentioned earlier, tension pneumothorax can lead to compression of the heart, including the ventricles. This compression can cause dilatation of the ventricles, particularly the right ventricle, due to increased afterload and decreased venous return.

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Correct Answer is A

Explanation

Choice A Reason:

The client has no sensation or movement below the level of the injury is correct. This is a characteristic finding of a complete spinal cord injury, where there is total loss of sensory and motor function below the level of the injury. This pattern is often seen in injuries involving the cervical spinal cord, such as at the level of C7.

Choice B Reason:

The client has some movement but no sensation below the level of the injury is incorrect. This finding would be more indicative of an incomplete spinal cord injury, where there is partial preservation of sensory or motor function below the level of the injury. However, with a transection of the spinal cord at C7, it is less likely for the client to have retained movement below the level of injury.

Choice C Reason:

The client has some movement and also some sensation below the level of the injury is incorrect. This finding is not typically associated with a spinal cord injury at the level of C7. With a transection of the spinal cord at this level, there is typically complete loss of sensory and motor function below the level of the injury.

Choice D Reason:

The client has some sensation but no movement below the level of the injury is incorrect. This finding is more consistent with an incomplete spinal cord injury, where there may be partial preservation of sensory function but no motor function below the level of the injury. However, with a transection of the spinal cord at C7, it is less likely for the client to have retained sensation below the level of injury.

A. Falls B. Gunshot wounds C. Sporting accidents D. Motor vehicle accidents

Correct Answer is A

Explanation

Choice A Reason:

Falls is correct. Among individuals aged 65 years and older, falls are the most common cause of spinal cord injuries. As people age, they may experience changes in balance, mobility, and bone density, which can increase their risk of falling. Falls can occur both at home and in other environments, such as during outdoor activities or in healthcare settings. Spinal cord injuries resulting from falls in older adults can have significant consequences, including decreased mobility, chronic pain, and loss of independence.

Choice B Reason:

Gunshot wounds is incorrect. Gunshot wounds can cause spinal cord injuries, but they are not the most common cause for individuals aged 65 years and older. Gunshot wounds tend to be more common in younger age groups or in specific contexts such as violence-related incidents, which are less frequent in older adults.

Choice C Reason:

Sporting accidents is incorrect. Sporting accidents can also lead to spinal cord injuries, especially in younger and more active individuals participating in high-impact sports. However, among individuals aged 65 years and older, participation in sporting activities that could result in spinal cord injuries is generally less common compared to younger age groups.

Choice D Reason:

Motor vehicle accidents is incorrect.

Motor vehicle accidents can cause spinal cord injuries, but they are not as common in the elderly population as they are in younger age groups. Older adults may have reduced driving frequency or may be more cautious on the road, which decreases their risk of motor vehicle accidents compared to younger individuals.

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A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a transection of the spinal cord at the level of cervical 7. Which of the following assessment findings should the nurse anticipate?

Correct Answer is A

Explanation

A nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?

Correct Answer is A

Explanation

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