A patient, who is on complete bed rest following extensive surgery, begins to complain of chest pain and shortness of breath with hemoptysis.
His SO2 measures 90%. The nurse recognizes that the patient is most likely exhibiting signs and symptoms of which condition?
Deep vein thrombosis (DVT).
Pulmonary embolus (PE).
Anemia.
Right heart failure (RHF).
The Correct Answer is B
Choice A rationale
Deep vein thrombosis (DVT) can lead to pulmonary embolism but does not directly cause chest pain and shortness of breath.
Choice B rationale
Pulmonary embolus (PE) is characterized by chest pain, shortness of breath, and hemoptysis (coughing up blood), especially in patients on bed rest.
Choice C rationale
Anemia can cause fatigue and shortness of breath but not typically chest pain and hemoptysis.
Choice D rationale
Right heart failure can cause shortness of breath and edema but not typically chest pain and hemoptysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Administering antihypertensive medication as prescribed is the priority action for a client with a history of hypertension presenting with severe headache, blurred vision, and confusion.
These symptoms suggest a hypertensive crisis, which requires immediate blood pressure reduction to prevent further complications.
Choice B rationale
Preparing the client for a lumbar puncture is not the priority action in this scenario. While a lumbar puncture may be necessary to rule out other conditions, the immediate concern is to manage the hypertensive crisis.
Choice C rationale
Initiating seizure precautions is important if the client is at risk of seizures, but the priority action is to address the hypertensive crisis by administering antihypertensive medication.
Choice D rationale
Monitoring the client’s blood glucose levels is important for overall health management, but it is not the priority action in this scenario. The immediate concern is to manage the hypertensive crisis.
Correct Answer is A
Explanation
Choice A rationale
A positive Brudzinski’s sign is indicative of meningitis. It involves involuntary lifting of the legs when the neck is flexed, suggesting meningeal irritation.
Choice B rationale
A positive Babinski’s sign indicates central nervous system pathology but is not specific to meningitis. It involves dorsiflexion of the big toe when the sole of the foot is stimulated.
Choice C rationale
A positive Romberg’s sign indicates issues with proprioception and balance but is not specific to meningitis. It involves swaying or falling when standing with eyes closed.
Choice D rationale
A positive Murphy’s sign indicates gallbladder inflammation (cholecystitis) and is not related to meningitis. It involves pain on palpation of the right upper quadrant during inspiration.
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