A client is admitted to the emergency department several hours after a motor vehicle crash. The car's driver-side airbag was activated during the accident. Which assessment requires the nurse's immediate intervention?
a. Disorientation
b. Hemoptysis
c. Pulse oximetry reading of 94%
d. Chest pain with movement
B
The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage ac-companies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs. The pulse oximetry reading is within normal limits and chest pain is expected with movement after chest trauma. Disorientation needs to be investigated, but does not take priority over a breathing problem.
You might also like to view...
A client with hepatitis C is being treated with ribavirin (Copegus). What nursing action takes priority?
a. Educating the client on ways to remain complaint with the drug regimen b. Teaching the client that transient muscle aching is a common side effect c. Ensuring that the client returns to the clinic each week for follow-up care d. Showing the client how to take and record a radial pulse for 1 minute
During a sleep study, which of the following groups of information are gathered?
a. Airflow, snoring, and tonsil size b. Electroencephalogram, electrocardiogram, and end-tidal carbon dioxide c. Oxygen saturation, number of arousals, and airflow d. Frequency of awakenings, REM speed, and apnea-hypopnea index
When working with low-income disabled families who have young children, the nurse recognizes that the children who are at greatest risk for abuse have:
a. Physical disabilities b. Developmental delays c. Mental retardation d. Cognitive disabilities
A toddler shows fear and begins to cry when her parent leaves her at day care. According to Havighurst, which developmental task would this child be exhibiting?
1. Building wholesome attitudes toward oneself 2. Learning to get along with age-mates 3. Learning to relate emotionally 4. Achieving personal independence