A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of apneumothorax?

Inspiratory stridor

Expiratory wheeze

Coarse crackles

Absence of breath sounds.

Answer and Explanation

The Correct Answer is D

A. Inspiratory stridor - This is associated with upper airway obstruction and is not indicative of a pneumothorax.

B. Expiratory wheeze - Wheezing is commonly associated with lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD), not pneumothorax.

C. Coarse crackles - Coarse crackles are typically heard in conditions such as pneumonia or pulmonary edema, not pneumothorax.

D. Absence of breath sounds - This is a key manifestation of a pneumothorax. The air in the pleural space can prevent the lung from fully expanding, leading to the absence of breath sounds on the affected side.

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Correct Answer is B

Explanation

a. Instruct the client to tilt her head back when she swallows: This action is not recommended, as it increases the risk of aspiration. Tilted head positions can lead to improper bolus control and

swallowing difficulties.

b. Add thickener to fluids: This is an appropriate intervention for a client with dysphagia, as thickened fluids are easier to control during swallowing and reduce the risk of aspiration.

c. Place food on the left side of the client's mouth: This action may not directly address the risk of aspiration associated with dysphagia and left-sided weakness.

d. Serve food at room temperature: While serving food at room temperature may be preferred for some clients, it does not directly address the safety concerns associated with dysphagia and left- sided weakness.

A. Encourage the client to take small bites. B. Place food in the unaffected side of the mouth. C. Offer mouth care before meals. D. Place the client in the upright position.

Correct Answer is D

Explanation

a. Encourage the client to take small bites: While encouraging small bites is important, the priority for a client with dysphagia is to ensure they are in an upright position to prevent aspiration.

b. Place food in the unaffected side of the mouth: Placing food in the unaffected side of the mouth may not prevent aspiration and does not address the priority of positioning.

c. Offer mouth care before meals: While oral hygiene is important, it is not the priority when addressing the risk of aspiration during feeding.

d. Place the client in the upright position: The upright position helps prevent aspiration during swallowing, which is crucial for clients with dysphagia.

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A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of apneumothorax?

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