a nurse in an emergency department is caring for a client who has sustained multiple injuries the nurse observes the clients thorax moving inward duri

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?

A. Flail chest
B. Hemothorax
C. Pulmonary contusion
D. Pneumothorax

Correct answer: A

Rationale: The correct answer is A: Flail chest. Flail chest results from multiple rib fractures, causing paradoxical chest movement where the injured part moves inward during inspiration and outward during expiration, interfering with ventilation. Choice B, Hemothorax, involves blood in the pleural cavity and does not typically cause paradoxical chest movement. Choice C, Pulmonary contusion, is a bruise to the lung tissue and does not present with paradoxical chest movement. Choice D, Pneumothorax, is the presence of air in the pleural space, leading to lung collapse, but it does not demonstrate paradoxical chest movement like in flail chest.

2. A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?

A. I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league.
B. I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running.
C. I'm so upset that this happened to me. What did I do to deserve this?
D. I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family.

Correct answer: A

Rationale: Choice A is the correct answer because it shows that the client has accepted their disability and is looking towards the future with realistic goals. This positive attitude and focus on engaging in activities that are achievable despite the disability indicate effective coping mechanisms. Choice B is incorrect as it reflects denial of the permanent nature of the disability. Choice C is incorrect as it shows feelings of anger and possible self-blame, which are not indicative of effective coping. Choice D is incorrect as it demonstrates a sense of hopelessness and self-perceived burden, which are signs of maladaptive coping.

3. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

A. Axillary temperature 37.2°C (99°F)
B. Apical pulse 100/min
C. Respiratory rate 30/min
D. Blood pressure 140/84 mm Hg

Correct answer: C

Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.

4. What symptoms are associated with a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Loss of motor function with nausea
D. Severe headache and vomiting

Correct answer: A

Rationale: A thrombotic stroke presents with a gradual loss of function on one side of the body due to a clot blocking blood flow to the brain. This gradual onset distinguishes it from a hemorrhagic stroke with sudden symptoms like loss of consciousness (Choice B), and from other conditions like migraine, which may present with severe headache and vomiting (Choice D). Nausea (Choice C) is not typically a primary symptom associated with a thrombotic stroke.

5. What are the characteristics of a thrombotic stroke?

A. Gradual onset over minutes to hours
B. Numbness on one side of the body
C. Associated with a loss of consciousness
D. Associated with seizures and convulsions

Correct answer: A

Rationale: The correct answer is A. Thrombotic strokes typically have a gradual onset over minutes to hours as they result from a clot obstructing blood flow. Choice B, numbness on one side of the body, is more commonly associated with an ischemic stroke rather than specifically a thrombotic stroke. Choice C, loss of consciousness, is not a defining characteristic of a thrombotic stroke. Choice D, seizures and convulsions, are more commonly seen in hemorrhagic strokes rather than thrombotic strokes.