When a client is admitted to the ED with tension pneumothorax and mediastinal shift following an automobile accident, the nurse would know that the client would exhibit
a. a sucking chest wound.
b. bradycardia.
c. mediastinal flutter.
d. severe hypotension.
D
Mediastinal shift may cause (a) compression of the lung in the direction of the shift and (b) compression, traction, torsion, or kinking of the great vessels; thus blood return to the heart is dangerously impaired. The latter causes a subsequent decrease in cardiac output and blood pressure.
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The nurse should know that once human immunodeficiency virus (HIV) enters the body, seroconversion to HIV positivity usually occurs within:
a. 6 to 10 days. b. 2 to 4 weeks. c. 6 to 12 weeks. d. 6 months.
The nurse suggests that a couple who are in the first trimester of pregnancy attend early prenatal classes. Which of the following topics would be covered in an early prenatal class?
A) Anatomy and physiology of childbirth, and choices B) Physical and emotional changes of pregnancy C) Supply list and information on nutrition to prevent anemia D) Desire for and confidence in vaginal birth and risks of cesarean section
The nurse is caring for a patient post cardiac catheterization who experiences a vasovagal response when his sheaths are removed and pressure is applied. Which of the following symp-toms is the patient likely to experience? (Select all that apply.)
a. Feeling faint b. Light-headed c. Flushing d. Dizzy e. Itching
A patient who has been hospitalized for 2 days remains anxious and continues to be preoccupied with paranoid delusions. What intervention will best help the patient focus less on the delusions?
a. Schedule time for the patient to read and listen to music. b. Plan activities that require physical skills and constructive use of time. c. Begin planning for discharge by engaging the patient in psychoeducation. d. Discuss personal goals related to improved socialization with the patient.