Which of the following could the nurse expect to observe in an older adult client who has a pneumothorax?

Higher oxygen saturations of 98% to 99%

Lower oxygen saturations of 93% to 94%

Lower energy expenditure

Increased lung capacity

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Higher oxygen saturations of 98% to 99% is inappropriate. A pneumothorax involves the presence of air in the pleural space, which can compromise lung function and gas exchange. This compromised lung function typically leads to decreased oxygenation of the blood, resulting in lower oxygen saturations rather than higher saturations.

Choice B Reason:

Lower oxygen saturations of 93% to 94% is appropriate. A pneumothorax disrupts the normal exchange of oxygen and carbon dioxide in the lungs due to partial or complete lung collapse. As a result, the affected lung is unable to adequately oxygenate the blood, leading to lower oxygen saturations, which are indicative of hypoxemia.

Choice C Reason:

Lower energy expenditure is inappropriate. Energy expenditure is not typically affected by a pneumothorax. While the discomfort and respiratory distress associated with a pneumothorax may cause the individual to limit physical activity, there is no direct impact on overall energy expenditure.

Choice D Reason:

Increased lung capacity is inappropriate. A pneumothorax results in partial or complete collapse of the affected lung, reducing lung capacity rather than increasing it. The presence of air in the pleural space creates positive pressure, which can compress the lung and decrease its ability to expand fully during inhalation.

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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. Place the client on clear liquids. B. Perform a hemoccult blood test. C. Insert a nasogastric tube. D. Force the intake of fluids.

Correct Answer is C

Explanation

Choice A Reason:

Placing the client on clear liquids might not be appropriate in this situation because absent bowel sounds in the lower abdominal quadrants could indicate a more serious gastrointestinal issue such as ileus or bowel obstruction. Clear liquids may exacerbate these conditions and are not sufficient to address the underlying problem. Therefore, this option is not recommended until the cause of absent bowel sounds is identified and addressed.

Choice B Reason:

Performing a hemoccult blood test is not directly relevant to the situation described. Hemoccult tests are used to detect occult (hidden) blood in stool, which can be indicative of gastrointestinal bleeding. While it's important to assess for gastrointestinal bleeding in some cases, absent bowel sounds in the lower abdominal quadrants suggest a more immediate concern related to gastrointestinal motility rather than bleeding. Therefore, this option is not the most appropriate action at this time.

Choice C Reason:

Inserting a nasogastric tube is the most appropriate action in this scenario. Absent bowel sounds in a client with a spinal cord injury can indicate neurogenic bowel dysfunction, which may lead to abdominal distention and discomfort. Inserting a nasogastric tube can help decompress the stomach and intestines, reducing the risk of complications such as aspiration and providing relief from discomfort. It can also help manage gastrointestinal complications until further assessment and interventions can be implemented.

Choice D Reason:

Forcing the intake of fluids may not be appropriate without further assessment and could potentially worsen the client's condition if there is an underlying gastrointestinal issue leading to absent bowel sounds. Additionally, forcing fluids may not address the potential issue of gastrointestinal bleeding.

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Which of the following could the nurse expect to observe in an older adult client who has a pneumothorax?

Nursing Test Bank

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 caring for a client who has a spinal cord injury and has absent bowel sounds in the lower abdominal quadrants. Which of the following actions should the nurse perform?

Correct Answer is C

Explanation

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