A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.)
(Select All that Apply.)

Pleural cavity decompression via needle aspiration

Focused assessment with sonography in trauma (FAST)

Chest x-ray

Thoracentesis

Ultrasound

Answer and Explanation

Correct Answer : B,C,D,E

Choice A Reason:

Pleural cavity decompression via needle aspiration is inappropriate. Pleural cavity decompression via needle aspiration may be indicated in cases of tension pneumothorax, a potentially life-threatening condition in which air accumulates in the pleural space and compresses the lung. While it is an intervention rather than a diagnostic tool, it may be performed emergently if tension pneumothorax is suspected based on clinical findings.

Choice B Reason:

Focused assessment with sonography in trauma (FAST) is appropriate. FAST is a bedside ultrasound examination commonly used in trauma settings to rapidly assess for the presence of free fluid in the pericardial, pleural, and peritoneal spaces. It can help identify hemopericardium, hemothorax, or intra-abdominal hemorrhage, which may be indicative of thoracic injury.

Choice C Reason:

Chest x-ray is appropriate. Chest x-ray is a commonly used imaging modality for evaluating thoracic injuries. It can help visualize abnormalities such as rib fractures, pneumothorax, hemothorax, pulmonary contusions, or other traumatic injuries to the chest.

Choice D Reason:

Thoracentesis is appropriate. Thoracentesis is a procedure used to sample fluid from the pleural space for diagnostic or therapeutic purposes. It may be indicated if there is a suspicion of pleural effusion or if fluid accumulation is seen on imaging studies such as chest x-ray or ultrasound.

Choice E Reason:

Ultrasound is appropriate. Ultrasound can be used to evaluate various aspects of thoracic injuries, including the presence of pneumothorax, hemothorax, or pleural effusion. It is often used as part of the FAST examination but can also be performed separately for more detailed assessment.

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Correct Answer is A

Explanation

Choice A Reason:

Vasogenic cerebral edema is appropriate response. Vasogenic cerebral edema occurs due to disruption of the blood-brain barrier (BBB), leading to leakage of fluid and proteins from the blood vessels into the brain parenchyma. This type of cerebral edema is commonly associated with conditions such as brain tumors, abscesses, and ischemic stroke.

Choice B Reason:

Osmotic cerebral edema is inappropriate response. Osmotic cerebral edema occurs when there is an imbalance of osmotic forces across the blood-brain barrier, leading to the movement of water into the brain cells. This type of cerebral edema can result from conditions such as hyponatremia or the administration of hypertonic solutions.

Choice C Reason:

Cellular cerebral edema is inappropriate response. Cellular cerebral edema involves the swelling of brain cells (neurons and glial cells) due to various insults, such as ischemia, hypoxia, or metabolic disturbances. This type of cerebral edema can occur in conditions such as ischemic stroke or traumatic brain injury.

Choice D Reason:

Interstitial cerebral edema is incorrect response. Interstitial cerebral edema involves the accumulation of fluid within the interstitial spaces of the brain tissue. This type of cerebral edema can occur in conditions such as hydrocephalus, where there is obstruction of cerebrospinal fluid (CSF) flow.

A. Refrain from climbing ladders. B. Do not go swimming without a partner. C. Refrain from driving unless seizure-free for 3 months. D. Avoid using power tools. E. Place client on the floor when having a seizure. F. Place client on their back when they are recovering from a seizure.

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Choice A Reason:

Refraining from climbing ladders is appropriate. Climbing ladders involves a risk of falling, which can be particularly hazardous for individuals with epilepsy. Seizures can occur unexpectedly and may cause loss of muscle control or consciousness, increasing the risk of falls from heights such as ladders. Falling from a ladder during a seizure can result in serious injuries, including head trauma, fractures, or other injuries from impact. Advising the client to refrain from climbing ladders helps mitigate the risk of falls and associated injuries during a seizure episode, promoting their safety and well-being.

Choice B Reason:

Do not go swimming without a partner is inappropriate. Swimming alone can be dangerous for individuals with epilepsy as they may be at risk of drowning if they experience a seizure while in the water. Having a swimming partner can provide assistance and ensure safety in case of a seizure.

Choice C Reason:

Refraining from driving unless seizure-free for 3 months is appropriate. Driving restrictions are often recommended for individuals with epilepsy to minimize the risk of accidents caused by seizures. Many jurisdictions require individuals with epilepsy to be seizure-free for a certain period, typically around 3 to 6 months, before resuming driving.

Choice D Reason:

Avoiding using power tools is appropriate. Operating power tools or machinery can be hazardous if a seizure occurs, potentially leading to serious injuries. Therefore, individuals with epilepsy should avoid using power tools to reduce the risk of accidents during a seizure.

Choice E Reason:

Placing client on the floor when having a seizure is appropriate. Placing the client on the floor during a seizure helps prevent injury from falls. It is safer to have the individual lie down on a flat surface to reduce the risk of head injury or other trauma during the seizure.

Choice F Reason:

Placing client on their back when they are recovering from a seizure appropriate. Placing the client on their back after a seizure helps maintain an open airway and facilitates recovery. This position allows for proper breathing and circulation while monitoring the individual's condition.

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A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.) (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a student about cerebral edema. The student nurse asks, "What type of cerebral edema is associated with a client who has a stroke?" Which of the following is the best response from the nurse?

Correct Answer is A

Explanation

A nurse is providing discharge instructions to a client who has epilepsy. Which of the following instructions should be included in the nurse's teaching? (Select All that Apply.)

Correct Answer is ["A","B","C","D","E","F"]

Explanation

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A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.)
(Select All that Apply.)