A nurse is caring for a client who has a tension pneumothorax. Which of the following manifestations should the nurse expect?

Paradoxical chest movement

Bilateral crackles

Asymmetry of the chest

Blood-tinged sputum

Answer and Explanation

The Correct Answer is C

Rationale:

A. Paradoxical chest movement: Paradoxical chest movement is typically associated with flail chest, where multiple rib fractures cause a segment of the chest wall to move in the opposite direction during breathing. It is not a characteristic finding of tension pneumothorax, which involves intrathoracic pressure buildup rather than rib instability.

B. Bilateral crackles: Bilateral crackles are usually indicative of fluid in the alveoli, such as in pulmonary edema or pneumonia. Tension pneumothorax generally causes decreased or absent breath sounds on the affected side, not crackles, due to lung collapse.

C. Asymmetry of the chest: Tension pneumothorax often causes visible asymmetry of the chest because the affected side may appear distended while the other side may appear sunken. The increased intrathoracic pressure pushes mediastinal structures toward the unaffected side, making chest asymmetry a hallmark sign.

D. Blood-tinged sputum: Blood-tinged sputum is more commonly seen with pulmonary infections, trauma to the airway, or pulmonary embolism. It is not a primary manifestation of tension pneumothorax, which is primarily characterized by respiratory distress and unilateral findings.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. "What questions do you have about reading food labels?": This question assesses nutrition literacy rather than dietary acculturation. It focuses on understanding nutritional information, not cultural food practices or adaptations.

B. "Do you have special customs that you follow for meals?": This question directly addresses dietary acculturation by exploring cultural or traditional food practices and meal patterns. It helps the nurse understand how the client’s cultural background influences their diet and eating behaviors.

C. "Are there any foods that you are allergic to?": This question assesses food safety and potential allergens, not cultural or acculturation aspects of the diet.

D. "How do you feel about your current body weight?": This question addresses body image and personal perception, which may influence dietary choices but does not provide information about cultural or acculturation influences on diet.

A. Contraction intensity increased by ambulation B. Presence of bloody show C. Slow change in dilation and effacement D. intermittent, painless contractions

Correct Answer is D

Explanation

Rationale:

A. Contraction intensity increased by ambulation: True labor contractions typically intensify with walking or activity, as the uterus works to dilate and efface the cervix. If contractions strengthen with movement, it suggests active labor rather than false labor.

B. Presence of bloody show: Bloody show indicates cervical changes with effacement and dilation, which are signs of true labor. Its presence helps differentiate true labor from false labor.

C. Slow change in dilation and effacement: True labor is characterized by progressive cervical change. Slow or minimal change in dilation and effacement is more consistent with false labor, but the primary hallmark is the nature of contractions.

D. Intermittent, painless contractions: False labor (Braxton Hicks contractions) is usually irregular, intermittent, and painless or minimally uncomfortable. They do not cause consistent cervical change and often subside with rest or position changes, making this a key distinguishing feature.

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A nurse is caring for a client who has a tension pneumothorax. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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