Exhibits
Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.
Course breath sounds
Irritability
Seizure activity
Decreased level of consciousness
Bradycardia
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}
Coarse breath sounds are typically associated with respiratory distress, indicating fluid or secretions in the airways.
Irritability can be a sign of both cerebral edema and respiratory distress as it may stem from hypoxia or increased intracranial pressure.
Seizure activity is more specifically related to cerebral edema, which can increase intracranial pressure and provoke seizures.
Decreased level of consciousness can occur in both conditions: cerebral edema (due to increased intracranial pressure) and respiratory distress (due to hypoxia).
Bradycardia is more indicative of cerebral edema, especially when associated with increased intracranial pressure and resultant autonomic dysregulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reviewing the blood pressure measurement is not the primary concern here; the issue is that the UAP is using the incorrect arm for the measurement.
B. The blood pressure should be measured on the non-operative side. Measuring on the operative side can cause discomfort, potential injury, or interfere with the healing process.
C. Elevating the arm after recording the blood pressure is not a standard requirement post-mastectomy. The immediate concern is the proper measurement site for the blood pressure.
D. A manual blood pressure cuff is not required for accuracy in this situation; the key issue is to use the non-operative arm for measurement.
Correct Answer is B
Explanation
A. While it’s important to keep the client calm, this task may not be the most critical or appropriate for a UAP in an emergency situation. The nurse typically leads in managing the client's immediate needs.
B. This is a crucial task because the PN will need sterile supplies (e.g., sterile saline, dressings) to manage the evisceration. The UAP can efficiently gather these supplies, allowing the PN to focus on assessing the client and providing immediate care. This delegation is appropriate because it helps expedite the response to a critical situation.
C. Covering the wound is a critical step in managing evisceration, which should be performed by the PN to ensure it is done correctly and to maintain sterile technique. The PN is responsible for the clinical management of the emergency.
D. Repositioning the client could exacerbate the situation or delay necessary interventions. The PN must assess and manage the evisceration while ensuring the client remains as stable as possible.
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