Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?
Clubbing of the fingernails
Tracheal deviation
Contraction of the diaphragm
Auscultation of rhonchi throughout the lungs
The Correct Answer is B
A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Furosemide is a diuretic that is used to reduce fluid overload and manage conditions like heart failure or kidney disease. It is not indicated in anaphylaxis.
B. Methylprednisolone is a corticosteroid used for its anti-inflammatory properties and can be used in anaphylaxis to reduce inflammation and prevent delayed reactions. However, it is not the first-line treatment in acute anaphylactic shock.
C. Epinephrine is the first-line treatment for anaphylactic shock. It works by rapidly reversing the effects of anaphylaxis, such as bronchoconstriction, vasodilation, and edema, by stimulating alpha and beta receptors. Epinephrine should be administered as soon as anaphylaxis is suspected to stabilize the patient’s condition.
D. Dobutamine is a medication used to manage shock by increasing cardiac output, but it is not used in the management of anaphylactic shock. The priority is epinephrine to reverse the anaphylactic response.
Correct Answer is A
Explanation
A. Pheochromocytoma is a tumor of the adrenal glands that can cause excessive production of catecholamines (such as norepinephrine and epinephrine), leading to a hypertensive crisis. This condition can cause severe hypertension, headaches, palpitations, and sweating.
B. Adrenal insufficiency is typically associated with low blood pressure, not hypertension. It is characterized by symptoms like weakness, fatigue, and hypotension, which are not linked to hypertensive crises.
C. Hypothyroidism is associated with low blood pressure and bradycardia, not an increased risk of hypertensive crisis. It typically leads to symptoms like weight gain, fatigue, and cold intolerance.
D. Diabetes insipidus is a condition that leads to excessive urination and thirst due to a lack of antidiuretic hormone, but it does not directly lead to a hypertensive crisis. It is primarily concerned with electrolyte imbalance and dehydration.
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